Gastroenterology Coding Alert

Question: A Medicare patient underwent a colonoscopy in the morning. He returns to the same provider in the evening for control of post procedural bleeding. How do we report this scenario?

Minnesota Subscriber

Answer: Control of post procedural bleeding is included in endoscopic procedures and you need not report that separately. In this case, for the colonoscopy procedure, you may report 45382 (Colonoscopy, flexible; with control of bleeding, any method). As for the return of the patient for addressing post procedural bleeding, append with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). Use of this modifier refers to complications that made the patient to revisit the provider.

However, if the provider has to repeat an endoscopy for control of bleeding in a separate patient encounter on the same date of service, you may report the HCPCS/CPT^® code for endoscopy for control of bleeding separately with modifier 78.

Careful:  Do not use modifier 77 (Repeat procedure or service by another physician or other qualified health care professional) and 76 (Repeat procedure or service by same physician or other qualified health care professional) here, as you can report these only when the physician performs the same procedure twice. However, in the given scenario, the purpose of initial colonoscopy was quite different from the second procedure, which the provider performed to control bleeding predominantly.