Gastroenterology Coding Alert

Question: A patient was seen for rectal bleeding and underwent a colonoscopy with polypectomy. Three days later he returned with signs of GI bleeding. A colonoscopy was repeated, and old blood was found in the colon (without any signs of active bleeding). Two days later, he returned with blood in the stool and was scoped again. This time, the bleeding site was identified as the previous polypectomy site with a visible vessel, which was cauterized during this procedure. I billed the procedures with 998.11, and the procedure was denied as not medically necessary. Which code should I have used?

Idaho Subscriber

Answer: Medicare sets out specific codes that support medical necessity for colonoscopies. According to Empire Medicare's local medical review policy, 998.11 (Hemorrhage complicating a procedure) does not substantiate the need for a colonoscopy. However, you have several choices next time this issue comes up. For example, a colonoscopy is indicated for the evaluation of unexplained gastrointestinal bleeding (578.1, 578.9) that is shown by presence of blood in the stool.

The last colonoscopy could be reported with 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 could report diagnosis code 792.1 (Nonspecific abnormal findings, stool contents) for occult blood found in the stool or 578.9 (Hemorrhage of gastrointestinal tract, unspecified). This is in contrast to the codes for the first diagnostic colonoscopy with polypectomy: a code for the removal of the polyp during the colonoscopy (45383-45385) and a corresponding diagnosis code, such as 211.3 (Benign neoplasm of colon).

Most colonoscopies do not have a global surgery period, so repeat procedures should be reimbursed as long as proper documentation and diagnosis codes accompany the report. Remember to append modifier -76 (Repeat procedure by same physician) to the subsequent colono-scopies performed on the same date of service. Always report the most specific diagnosis code.