Gastroenterology Coding Alert

Question: Our gastroenterologist performed a colonoscopy during which he removed a polyp using the snare technique in the transverse colon. He also used bipolar cautery to stop gastrointestinal bleeding. How should I code for this scenario?

Missouri Subscriber

Answer: As long as your documentation proves two separate sites, this is a two-code claim -- but make sure you remember your ICD-9 codes. You 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]) with modifier 59 (Distinct procedural service), and be sure to include the proper ICD-9 code to reflect the separate finding that actively bled.

Depending on the operative note specifics, some suitable diagnosis codes for this situation might be 569.82 (Ulceration of intestine), 569.83 (Perforation of intestine), 569.84 (Angiodysplasia of intestine [without mention of hemorrhage]) or 569.85 (Angiodysplasia of intestine with hemorrhage]).
 
Report 45385 (... with removal of tumor[s], polyp[s] or other lesion[s] by snare technique), and include 211.3 (Benign neoplasm of other parts of digestive system; colon).
 
Modifier 59 appended to 45382 shows that the gastroenterologist treated two separate areas and that the polyp removal did not cause the bleeding.

Note: If the polyp removal caused the bleeding, you should include the service to stop the bleeding with the polyp removal code. You don't need any other code. Basically, the rule is -if you caused it, you fix it for free.-

Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.