Gastroenterology Coding Alert

Question: My gastroenterologist performed 45385, and discharged the patient. Later on the same day, the patient found blood in their stool and returned to the office. The physician, then, performed an inpatient consultation (99253), and did a colonoscopy with control of bleeding. Should I code 45382 for the bleed control?

Washington Subscriber

Answer: Since the physician performed the bleed control in a separate procedural session, you should bill 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 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). CCI guidelines (Version 15.3 Chapter VI Surgery: Digestive System of the National Correct Coding Initiative Policy Manual for Medicare Services) contain the following instructions:

"11. Control of bleeding is an integral component of endoscopic procedures and is not separately reportable. If it is necessary to repeat an endoscopy to control bleeding at a separate patient encounter on the same date of service, the HCPCS/CPT code for endoscopy for control of bleeding is separately reportable with modifier 78 indicating that the procedure required return to the operating room (or endoscopy suite) for a related procedure during the postoperative period."