Gastroenterology Coding Alert

Question: Our gastroenterologist diagnosed a patient with significiant lower gastrointestinal bleed status post polypectomy of the ascending colon a day ago. He observed bleeding at the polypectomy area of proximal ascending colon. How should I report this case based on the following physician’s note? Digital rectal examination was performed, after which the PCF160 video colonoscope was inserted into the rectum and advanced to the cecum. There was old blood throughout the whole colon. In the area of the proximal ascending colon, the site of the previous polypectomy was visualized with fresh clot hanging out, with drops of blood coming out under the clot. Those findings confirmed. The epinephrine injection submucosally was performed; first circumferentially at the polypectomy site. This arrested the bleeding. Now the clot was removed with cold biopsy forceps and the base of the polypectomy site was treated with Argon plasma coagulator. A nice eschar was achieved and bleeding was completely controlled. Upon withdrawal of the scope old blood was suctioned out as much as possible. There were other bleeding sites noted.

California Subscriber

Answer: All the interventions in this case were on the same polyp/lesion. The intent of the injection and the use of the Argon plasma coagulation were to control bleeding and therefore your claim 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]).

ICD-10: You would bill K92.2 (Gastrointestinal hemorrhage, unspecified) as primary diagnosis, and Z86.010 (Personal history of colonic polyps) as secondary.