Gastroenterology Coding Alert

Reader Questions:

Clear Up This Cold Forceps Biopsy Scenario

Question: I have a report that says, "Ileum appeared normal. Cold forceps biopsy taken for histology." How should I report this? Can I bill 45380? The ICD-9 codes my gastroenterologists gave are 787.99, 789.07, and 455.0.

California Subscriber

Answer: Yes, you can report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). Enter the ICD-9 codes in this order: 787.99 (Other symptoms involving digestive system; change in bowel habits), 789.07 (Abdominal pain; generalized), and 455.0 (Internal hemorrhoids without mention of complication).

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