Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed exam under anesthesia, anastomotic dilation using a Hegar dilator, flexible sigmoidoscopy. I wanted to use 45340 but it uses balloon dilation. Can any one help?

Houston Subscriber

Answer: It seems that your gastroenterologist performed the anastomotic dilation located near the rectum using the Hegar dilators and then performed a flexible sigmoidoscopy once the narrowing was sufficient to allow passage of the sigmoidoscope.  For the dilation you should report code 45910, (Stricture, anal or rectal, dilation or division under anesthesia other than local).

But, during the same procedure that he performed the dilation, your gastroenterologist also performed the flexible sigmoidoscopy. For the flexible sigmoidoscopy, if the doctor examines the entire rectum, sigmoid colon, and perhaps as far as the splenic flexure (26 cm-60 cm), you’d normally use a sigmoidoscopy code: 45330 (Sigmoidoscopy, flexible; diagnostic, with or without the collection of specimens by brushing or washings).

As per Correct Coding Initiative (CCI) edits,  the code 45910 is a column 2 code for 45330 with the modifier ‘0’ that indicates that these two codes cannot be reported together under any circumstances. The edits indicate the dilation that your gastroenterologist performed is considered bundled into the flexible sigmoidoscopy code. So you can only report 45330 and not report the dilation that your gastroenterologist performed in the same session prior to performing the sigmoidoscopy.