Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a pouchoscopy. The operative report read like this:

The patient was turned around and the scope was changed to an Olympus P CF-180 pediatric video colonoscope. There was an anal stricture but I was able to get the scope beyond this. There was inflamed tissue at 40 cm. I bypassed this. There was a stricture at 100 cm and I was unable to bypass it with the scope. I dilated that with a 20 mm balloon. Then I was able to bypass the stricture and the ileum proximal to it appeared normal. The colonoscope was slowly withdrawn and the ileum and pouch were decompressed. The anus was dilated with a 50 French Maloney dilator. The procedure was then terminated. He tolerated it well. There were no immediate complications.

Should I use a colonoscopy CPT® code to describe the procedure that was performed?

Georgia Subscriber

Answer: Colonoscopy is a diagnostic procedure used to detect problems in the colon or the rectum. A pouchoscopy is performed on the small intestinal (abdominal or pelvic) pouch. So, a colonoscopy CPT® code cannot be used if pouchoscopy is the procedure your gastorenteroloist is performing. If pouchoscopy was the only procedure that your gastroenterologist performed, then you have to report the procedure using 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). But, since your gastroenterologist also used dilators to overcome the strictures, if you only report the procedure with 44385, your reporting will only be half-correct.

CPT® does not cover many endoscopy procedures with separate codes. One such code that is not covered includes pouchoscopy along with dilation to overcome strictures using a balloon, bougie or a guidewire. Since, CPT® does not have a separate code for pouchoscopy with dilation you will have to report the pouchoscopy with 44385 and the dilation with 44799 (Unlisted procedure, intestine).

Since you are reporting an unlisted procedure code, you will have to submit a copy of the operative report along with documentation describing what additional procedures have been performed by your gastroenterologist. The documentation should also include the time that was taken by your gastroenterologist to perform the procedure.