Gastroenterology Coding Alert

Question: One of our gastroenterologists recently treated a patient's proctitis and continuous rectal bleeding. The gastroenterologist performed a sigmoidoscopy with biopsy during the first encounter, and then infused formalin into the rectum in-office during the second encounter (the infusion visit took 45 minutes). Can I report the formalin infusion and the sigmoidoscopy? I cannot find a CPT code for the formalin infusion.

South Dakota Subscriber

Answer: Report the first encounter with a standard sigmoidoscopy code. For the second encounter, there is no code for formalin infusion, but you may be able to gain payment by reporting an E/M service and a prolonged services code.

On the claim, you should:

- report 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) for the sigmoidoscopy

- report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the formalin infusion

- report +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient E/M service]) to account for the extra E/M time 

As for your ICD-9 codes, you should attach 569.3 (Hemorrhage of rectum and anus) and 569.49 (Other specified disorders of rectum and anus; other) to 45331, 99212 and 99354 to prove medical necessity for the visit.

Good advice: Because you are reporting a prolonged services code, documentation and diagnoses that prove medical necessity are vital for a healthy claim. Make sure the claim reflects the gastroenterologist's reasons for the formalin infusion and the most specific ICD-9 codes possible. Documentation should also include an explanation for the necessity of the prolonged physician service and a detailed description of what service the gastroenterologist provided during the prolonged service time.