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Question: A patient presented to their gastroenterologist with complaints of intermittent blood in their stool. The physician performed an anoscopy to assess the patient’s condition.

How do we report this procedure?

Tennessee Subscriber

Answer: The CPT^® code set features several codes for reporting anoscopy procedures. A provider typically performs the diagnostic exam to confirm that active bleeding is from hemorrhoids. However, you should review the procedure report to look for other keywords that will provide an indicator of which CPT^® code to assign.

For example, you’ll assign 46600 (Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) when the gastroenterologist performs diagnostic anoscopy with brushings to collect specimens for testing. If the provider performs a high-resolution anoscopy (HRA) with an acetic acid solution or other special stain to improve visibility and takes one or multiple biopsies, you’ll assign 46607 (Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple).

What happens: During an anoscopy, your gastroenterologist uses a short, rigid, hollow tube (anoscope) that may contain a light source to examine the last 5 to 10 cm of the colon, or anal canal. The doctor often performs an anoscopy in the office setting without sedation.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC