Gastroenterology Coding Alert

Question: When an anoscopy (46600) is performed during an office visit, can the office visit be reported in addition to the procedure?

Janel Flachsbart
Lincoln, Neb.

Answer: Whether the office visit can be billed separately with the anoscopy depends on the nature of the visits, says Cynthia Thompson, CPC, senior consultant at Gates, Moore & Company, a medical practice consulting firm in Atlanta. Although it may be tempting to try to boost the reimbursement for the anoscopy, which has a relative value unit that is slightly less than a mid-level office visit, do not unbundle the office visit from the procedure just to get paid.

The office visit will be billable separately if there is sufficient documentation to support your claim. This means that the appropriate levels of history, examination and medical decision-making for the office visit that you are going to report must be documented in the patients medical record. If the office visit was very limited in terms of the history, examination and medical decision-making, or if the payers policy indicates that an office visit and the anoscopy cannot be paid separately, then you should bill only for the procedure.

If there is enough documentation to bill the office visit separately, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be attached to the code for the office visit.