Gastroenterology Coding Alert

Question: The gastroenterologist recently saw a patient who was complaining of abdominal cramping, frequent bowel movements, and blood in the stool. The doctor suspected colitis and performed a proctosigmoidoscopy for evidence to back up the theory. What is that, and how do I code it?

Rhode Island Subscriber

Answer: You’ll code this procedure with a proctosigmoidoscopy code, such as 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)). Keep in mind the descriptor to 45300 refers to the word “rigid.” If the procedure report doesn’t clarify whether the physician used a rigid or flexible scope, you should ask for details, since the different instruments can refer to different codes.

Procedure refresh: During a proctosigmoidoscopy (45300- 45327), your gastroenterologist uses a sigmoidoscope to look at the inside of the rectum and sometimes also into the sigmoid colon. Usually, the physician advances the scope 6 to 20 cm into the colon.

Gastroenterologists frequently perform proctosigmoidoscopies in the office to evaluate conditions such as diarrhea with bleeding.