Gastroenterology Coding Alert

Question: A patient complaining of rectal pain reported to the office. The gastroenterologist performed a colonoscopy and found two bleeding polyps in the ileum, which she cauterized. Which CPT code should I use to report the procedure?

Idaho Subscriber

Answer: For the colonoscopy, you should report 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). You should also attach ICD-9 codes 569.42 (Other specified disorders of rectum and anus; anal or rectal pain) and 211.2 (Benign neoplasm of other parts of digestive system; duodenum, jejunum, and ileum) to 45382 to prove medical necessity.