Gastroenterology Coding Alert

Question: A patient who had a total colectomy and still had a rectal stump visited our office. Our gastroenterologist performed a flexible sigmoidoscopy with biopsy (with colonoscope). How should I code this procedure? Can this be billed as a flexible sigmoidoscopy since the patient only has a rectal stump? In another case, our GI performed a screening colonoscopy on a 59-year-old patient and found a 2.5-cm pedunculated polyp in the rectosigmoid region, which he removed through colonoscopy using an endoloop. How do I bill this polyp removal?

Arkansas Subscriber

Answer: Although the provider did not use a proctosigmoidoscope and used a colonoscope (which is flexible, not rigid), you still can’t report a colonoscopy code since the physician did not examine the entire colon.

According to the information you’ve shared, the patient previously had a total colectomy. In your situation, the gastroenterologist performed a visualization of the rectal stump with biopsy. Therefore, even though the provider used a colonoscope, the most appropriate CPT^® code here is 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). You should also append modifier 52 (Reduced services) to the procedure code since the physician examined the anus and rectum but not the sigmoid, since it was surgically removed.

In the second case, an endoloop is a detachable snare device used for hemostasis (control of bleeding) during procedures such as endoscopic polyp removal. Whatever the terminology, as the endoloop uses the “snare technique,” you would report the procedure with polypectomy code 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) for the rectosigmoid polyp.