Gastroenterology Coding Alert

Follow Endoscopic family rules for any therapeutic services during the procedure.

Your gastroenterologist might sometimes opt for a shorter proctosigmoidoscopy procedure to examine a patient with rectal hemorrhage or pain instead of a more extensive sigmoidoscopy. Because gastroenterologists perform both procedures by inserting the scope through the anus, you have to be on your toes to choose the correct family of codes to bill your physician’s services.

Cross out these pre-requisites from your list before finalizing your claim to pin-point the right codes for the proctosigmoidoscopy procedure and reap max benefits for any therapeutic services performed during the endoscopy.

1. Endoscopy Documentation Mentions “Distal Portions”

The first step that can give you a clue about the exact type of endoscopy procedure your GI performed is to check the patient’s notes to see which part of the colon was examined.

Secondly, a mention of the type of scope that your gastroenterologist used to perform the procedure may also give you a direct idea about the difference between a proctosigmoidoscopy and a flexible sigmoidoscopy. Documentation should point to the specific type of scope used, rigid or flexible, as well as the parts of the colon examined. “Since proctosigmoidoscopy involves only examining the distal portions of the sigmoid colon and rectum, your gastroenterologist may use a rigid scope (a ‘proctoscope’) in comparison to a flexible scope when performing a sigmoidoscopy,” says Michael Weinstein, MD, the Chair of Health Policy for DHPA. If the GI has used a rigid scope to view the rectum and sigmoid colon then you should latch on to the family of proctosigmoidoscopy CPT^® codes 45300-45327 (Proctosigmoidoscopy, rigid..).

However, a rigid scope has limited viewing ability due to the inability to bend at the sigmoid flexure, and your physician may decide to use a flexible scope if he wants to visualize the rectum, the sigmoid colon and a portion of the descending colon and maneuver beyond the splenic flexure and reach into these areas of the GI tract. If a flexible scope is used to view the rectum, sigmoid colon, and/or the descending colon then you should use codes 45330-45345 (Sigmoidoscopy, flexible..).

Scenario: A patient presents to your GI with rectal pain and bleeding. The physician schedules a lower GI endoscopy and during the encounter, advances a rigid scope to visualize the rectum and the distal sigmoid colon. You can be sure that your gastroenterologist performed a proctosigmoidoscopy. Since your gastroenterologist only visualized the area without performing any other procedures, you can report the encounter with 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

2. Scope Traveling Distance Remains Within 25 cm

During a proctosigmoidoscopy, your gastroenterologist will pass the scope up to a maximum distance of 25 cm. If your gastroenterologist advances the scope to a distance between 6 cm to 25 cm, you can be assured that he has performed a proctosigmoidoscopy while a distance between 26 cm to 60 cm is indicative that he performed a sigmoidoscopy.

Scenario: Your gastroenterologist assesses a patient for hemorrhage of the rectum (K62.5, Hemorrhage of anus and rectum). After administration of anesthesia, your gastroenterologist uses a rigid scope that is inserted anally to a distance of 24 cm. Your gastroenterologist visualizes the anal canal, rectum and the sigmoid colon. Since a rigid scope was used and was only advanced to a distance of 24 cm, you can be assured that your gastroenterologist undertook a proctosigmoidoscopy and not a sigmoidoscopy.

3. You Have Factored in All Therapeutic Services Performed

Once you have ascertained from the direction of approach, type of scope and extent of scope insertion that your gastroenterologist performed a proctosigmoidoscopy, you will have to look at the patient notes more closely to see if he only visualized the rectum and sigmoid colon or if he performed any other therapeutic procedures during the same session. If your gastroenterologist only visualized the rectum and sigmoid colon, you report the base code 45300.

However, if your gastroenterologist performed any other procedures during a proctosigmoidoscopy, you can choose from among these codes:

Dilation: 45303 -- Proctosigmoidoscopy, rigid; with dilation (e.g., balloon, guide wire, bougie)

Biopsy: 45305 -- (..with biopsy, single or multiple)

Polyp or foreign body removal: 45307- 45315

Control of bleeding: 45317 (..with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator])

Tumor ablation: 45320 (..with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [e.g., laser])

Stent placement: 45327 (..with transendoscopic stent placement [includes predilation])

Example 1: Your gastroenterologist performs a proctosigmoidoscopy and performs a biopsy to sample a lesion for malignancy. You report 45305 for the encounter.

Caution: You must report 45305 only once even when the physician biopsied more than one location in the same region.

Example 2: Suppose he removed two polyps using hot biopsy forceps and one tumor by ablation; you report 45320 for the ablation and 45315 for the removal using hot biopsy forceps. As Correct Coding Initiative (CCI) edits bundles 45320 and 45315 with modifier ‘1,’ you will need to append modifier 59 (Distinct procedural service) to 45315 to report both the services during the same encounter.

4. Any Separate E/M Service is Covered

A proctosigmoidoscopy is often done in the office setting using a disposable rigid examination tube and a reusable light source. A proctosigmoidoscopy does not require the more elaborate and expensive equipment typical of standard endoscopic devices. It also does not require a prolonged preparation or intravenous conscious sedation.

Therefore, the physician can recommend a proctosigmoidoscopy after an office evaluation of the patient and can perform the procedure at the same visit. You can bill for an E/M service (99201-99205, 99212- 99215) if there is documentation of a history, physical, and assessment that includes a plan to perform a proctosigmoidoscopy. The E/M service should be filed with a modifier 25 (Significant, separately identifiable evaluation and management services by the same physician or other qualified health care professional on the same day of the procedure or other service) and the proctosigmoidoscopy report should be documented separately from the office visit note.

Scenario: Your gastroenterologist sees a new patient with a four-week history of diarrhea and bleeding. During the encounter, your gastroenterologist takes a “detailed” history and performs a “detailed” physical exam. The “low complexity” assessment and plan includes a recommendation to immediately perform a proctosigmoidoscopy to look for distal colon inflammatory colitis. The procedure note reads that the rigid instrument was advanced to visualize the rectum and the distal sigmoid colon. A biopsy was obtained from the inflamed mucosa. Since your gastroenterologist documented a separate E/M office visit, you can report the encounter with 99203 (Office or other outpatient visit for the evaluation and management of a new patient..) with the modifier 25 appended to it and 45305 (Proctosigmoidoscopy, rigid; diagnostic, with biopsy, single or multiple).