Gastroenterology Coding Alert

Nugget: Gastroenterologists should indicate procedures done through stoma or done through ostomy to ensure appropriate billing and reimbursement.

The standard family of codes for colonoscopies via the rectum (45378-45385) is not used to report colonoscopies performed through a stoma in the abdominal wall. Instead, endoscopic procedures are reported with codes from the small bowel and stomal section of the CPT manual.

A stoma (or ostomy) is an opening created in the abdominal wall as a result of an intestinal resection, which is done to excise a diseased portion of the intestine. If the colon and rectum are removed, the surgeon performs an ileostomy to attach the ileum to the external stoma, according to James Frakes, MD, MS, FACP, FACG, a gastroenterologist from Rockford, Ill., and president of the American Society of Gastrointestinal Endoscopy. If only the rectum is removed, the surgeon performs a colostomy to attach the colon to the stoma.

As a follow-up procedure, diagnostic colonoscopies periodically are done on patients with colostomies, Frakes explains. Instead of inserting the endoscope through the rectum, it is inserted through the stoma and into the colon. Because of the different point of entrance into the body, 44388 (colonoscopy through stoma, diagnostic) is used to report the endoscopic procedure when performed on patients with colostomies instead of 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]), which is the code for reporting colonoscopies via the rectum.

The fact that the procedure is being done through a stoma should be clearly evident through the gastroenterologists notes in the patients medical record, according to Pat Stout, CMC, CPT, an independent gastroenterology coding consultant in Knoxville, Tenn. All the gastroenterologist has to do is document in the patients record that the procedure was done through stoma or done through ostomy, she explains. This tells the coder which family of codes to use.

Bundling Edits/Multiple Endoscopic Rules Apply

The bundling edits and multiple endoscopy rules that apply to the family of colonoscopy-through-stoma codes (44388-44394) are the same as those that apply to the family of codes for colonoscopy via the rectum (45378-45385), says Stout. For example, the control-of-bleeding code 44391 (colonoscopy through stoma; with control of bleeding, any method) is bundled into the colonoscopy-through-stoma polypectomy codes 44392-44394, just as 45382 (colonoscopy; with control of bleeding, any method) is bundled into the polypectomy codes for colonoscopies via the rectum (45383-45385).

Both control of bleeding and a polypectomy can be reported separately, Stout notes. The polypectomy is performed in a different part of the colon than the control of bleeding, just as it would be with a colonoscopy via the rectum.

If a polyp is removed by the snare technique during a colonoscopy through stoma (44394) and a control of bleeding is performed on an arteriovenous malformation (AVM), both procedures could be reported separately, according to Stout. But the special payment rules for multiple endoscopies would apply because both procedures have the same base endoscopic code (44388). The polypectomy by snare technique would be reimbursed at 100 percent of the standard fee because it is the higher-valued procedure, while reimbursement for code 44391 (colonoscopy through stoma; with control of bleeding, any method) would be the difference between the value of the procedure and its base endoscopic code.

Gastroenterologists should check the relative value units (RVUs) of all colonoscopy-through-stoma codes before filing a claim because they are slightly different than the RVUs for colonoscopy via rectum codes. In the previously cited example, the polypectomy by snare technique for a colonoscopy through stoma will be reimbursed at 100 percent of its standard fee because it has a higher RVU than the control of bleeding procedure. When the colonoscopy is done via the rectum, however, the control of bleeding procedure has the higher RVU and would be reimbursed at 100 percent of its standard fee, while payment for the polypectomy by snare technique would be the difference between the value of the procedure and its base endoscopic code.