Gastroenterology Coding Alert

Question: A patient who had total colectomy and still had a rectal stump visited our office. Our gastroenterologist performed a flexible sigmoidoscopy w/ biopsy (with colonoscope). How should I code this procedure? Can this be billed as a flex sig since patient only has rectal stump? In another case, our GI performed a screening colonoscopy on a 59-year-old patient and found a 2.5-cm pedunculated polyp in the rectosigmoid region, which he removed through colonoscopy using an endoloop. How do I bill this polyp removal?

Minnesota Subscriber

Answer: Although the provider did not use a proctosigmoidoscope and used a colonoscope which is flexible, not rigid, we still cannot take code from the colonoscopy series since colonoscopy was not performed due to absence of the entire colon.

According to your information, the patient has a history of total colectomy performed. What the gastroenterologist performed was a visualization of the rectal stump with biopsy. Therefore, even though the provider used a colonoscope, the most appropriate CPT^® code that can be used in this scenario is 45331; (Sigmoidoscopy, flexible; with biopsy, single or multiple). You should also attach modifier 52 (Reduced services) with the procedure code for reduced services since the physician examined the inner part of the anus and rectum without sigmoid colon using the colonoscope.

In the second case, an endoloop is a detachable snare device used for hemostasis (control of bleeding) during procedures such as endoscopic polyp removal. Whatever the terminology, as the endoloop uses “snare technique,” you would report the procedure with polypectomy code 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the rectosigmoid polyp. As a pedunculated polyp has a thick pedicle that with a feeding vessel and therefore a high potential for post-polypectomy bleeding, the gastroenterologist may sometimes use a loop ligating device like an endoloop (Polyloop; Olympus America, Inc.) deployed around the pedicle to act as a tourniquet to prevent excessive bleeding after the polyp is removed. During an endoloop placement, the physician opens the loop, maneuvering it around the polyp, and brings it down to the level of the pedicle. This deployment of the endoloop presents a unique challenge as the endoloop is not as stiff as a snare. Also, the correct positioning distance of the endoloop on the stalk is crucial so that polypectomy can be performed above the endoloop. The GI tightens the endoloop after securing the device in good position around the pedicle. The tightened endoloop around the stalk acts like a tourniquet, tamponading the vessel in the pedicle. The GI then manipulates the snare around the polyp and tightens it around the stalk, above the closed endoloop, and snare cautery polypectomy is performed.