Gastroenterology Coding Alert

Question: A 68-year-old established Medicare patient with a history of colonic polyps reports to the gastroenterologist for a scheduled screening sigmoidoscopy. The patient has never had a Medicare-covered gastrointestinal screening of any kind. During the screening, the gastroenterologist discovers a pair of lesions that he removes via ablation; tissue on both lesions was benign. How do I report this encounter?

Virginia Subscriber

Answer: On the claim, report the following:

• 45339 (Sigmoidoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for the sigmoidoscopy

• 211.3 (Benign neoplasm of other parts of digestive system; colon) appended to 45339 to represent the polyps

• V12.72 (Diseases of digestive system; colonic polyps) appended to 45339 to represent the patient's personal history.

Explanation: Once a screening sigmoidoscopy turns into a procedure, you should forget about screening code G0104 (Colorectal cancer screening; flexible sigmoidoscopy) and start looking at the 45330-45345 code set.