Gastroenterology Coding Alert

Highlighting how far the scope goes could be your clue.

Colonoscopy is not the only lower endoscopic procedure that a physician can consider for her patient. The three other endoscopic procedures of the lower gastrointestinal tract are just as important.

Here are 3 ways to approach coding a lower GI scope.

Seek Out 46600-46615 for Anoscopy

Scenario 1: A patient presents to your practice complaining of intermittent bright red blood in the stool. The gastroenterologist believes persistent hemorrhoids are causing the condition. He then performs an anoscopy.

Solution: If your physician wants to confirm that a patient's active bleeding is caused by hemorrhoids, he may opt to just examine the anal canal region with an anoscope (46600, Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Applicable anoscopy codes are 46600-46615 with the physician often performing most of these anoscopy procedures in the office setting.

On the side: Before deciding to perform an anoscopy your gastroenterologist will usually perform an office visit first that is unrelated to the anoscopy. You can report the visit using the office visit codes (99201-99215), but you should apply the different diagnosis that supports the separate office visit, and add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), explains Stephanie Goodfellow, billing supervisor for Mid-America Gastrointestinal Consultants in Kansas City, Mo. Documentation is very important to back up your claim, she adds.

What happens: During an anoscopy, your gastroenterologist uses a short, rigid, hollow tube (anoscope) that may contain a light source to examine the last 5-10 cm of the colon, or anal canal.

Learn the Scope of the Scope, And the Instrument

Scenario 2: A patient visits the physician complaining of abdominal cramps, frequent bowel movements, and blood in the stool. To look for the evidence of colitis, your gastroenterologist decides to perform a proctosigmoidoscopy.

Solution: When performing proctosigmoidoscopy (45300-45327), your gastroenterologist uses a slightly longer instrument than the anoscope to view the inside of the rectum. This exam may include the sigmoid colon as well, and the physician usually advances the scope 6-25 cm into the colon. Physicians often use proctosigmoidoscopes in the office to evaluate diarrhea with bleeding -- for instance, 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Learning how far the scope goes isn't important other than to help you recognize the procedure performed by your gastroenterologist. For instance, if the physician describes looking at 15 cm of the distal rectosigmoid then, that could not be an anoscope.

However, it could be either a rigid proctosigmoidoscope or a flexible sigmoidoscope. "The most important thing to identify in picking the correct code for these office procedures is the name of the instrument," says Michael L. Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. Look for anoscope, proctosigmoidoscope (or proctoscope), or flexible sigmoidoscope (a.k.a. flex sig or sometimes just sigmoidoscope), he adds. Coverage Dictates Different Sigmoidoscopy Coding Approach

Scenario 3: Your gastroenterologist performs a sigmoidoscopy in the office as part of routine colon cancer screening on a non-Medicare patient.

Solution: Sigmoidoscopy codes (45330-45345) apply when the flexible sigmoidoscope -- roughly 2 feet (61 cm) long and 0.5 in. (1.3 cm) wide with a lighted lens system using a fiberoptic viewing lens or a digital camera -- passes 26-60 cm into the colon up to the splenic flexure.

Advantage: Sigmoidoscopy allows for a more complete view of the lower colon than a rigid scope because the flexibility allows passage around the colon's bends. When examining a Medicare patient, you must use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) for a routine screening sigmoidoscopy rather than 45330-45345. In the past, ambulatory surgery centers (ASCs), billing for sigmoidoscopy with Medicare as the facility, reported G0104 with modifier SG (ASC facility service). However, ASCs stopped using modifier SG to designate the facility fee on Jan 1, 2008.

Remember: The anoscopy and proctosigmoidoscopy procedures are not approved facility procedures.