Gastroenterology Coding Alert

Question: How should I bill a claim based on this medical report? PREOPERATIVE DIAGNOSIS: History of Crohn disease with nodularity and deformity of the ileocecal valve region now followed with colonoscopy. POSTOPERATIVE DIAGNOSES: Severe deformity of the ileocecal valve region with ileal stricture formation status post biopsy, separate polypoidal process appearing within the caput cecum in the periappendiceal region status post biopsy submitted in a separate container. SERVICE: Colonoscopy with biopsies PROCEDURE: After the patient was placed in the left lateral decubitus position, the doctor administered anesthesia until the patient was sedated. Once adequately sedated, the video pediatric colonoscope was introduced into the patient's rectum and advanced into the cecum. Cecal location was confirmed by characteristic architecture and transillumination in the right lower quadrant. Within the caput cecum in the periappendiceal region, a polypoidal process was noted. Biopsies were obtained. The instrument was withdrawn to the ileocecal valve area, which had significant stricture formation, scarring and nodularity and a separate set of biopsies were obtained of this region. The instrument was withdrawn to the ascending and transverse colons where it was noted to have diverticulosis. In the rectum, no further pathology was seen. The instrument was withdrawn from the patient's anus. The patient tolerated the procedure well and returned to recovery room in satisfactory condition.

Washington, D.C. Subscriber

Answer: You should bill CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the procedure and if the procedure was performed in the office setting then expect to get about $473 in reimbursement (13.92 RVUs multiplied by the 2011 conversion factor of 33.9764). The amount of the reimbursement is $264.68 (7.79 RVUs multiplied by 2011 conversion factor of 33.9764) if the procedure is performed in a facility such as ambulatory surgery center or hospital outpatient endoscopy facility. Remember, you would report this code only once, no matter how many biopsies your gastroenterologist performs. Don't let the "multiple" in the code's descriptor fool you.

When your GI performs 45380, it means she's taking tissue samples using cold biopsy (disposable) forceps. These forceps are referred to as "cold" because no electric current passes through them.

Based on the report given, you should link the following ICD-9 codes with 45380:

• 751.5 -- Other congenital anomalies of intestine
• 560.9 -- Unspecified intestinal obstruction
• 211.3 -- Benign neoplasm of colon.