Gastroenterology Coding Alert

Question: One of the gastroenterologists in our practice was recently treating a patient with a diagnosis of proctitis and continuous rectal bleeding. The gastroenterologist performed a sigmoidoscopy with biopsy during the first encounter, then infused formalin into the rectum in-office during the second encounter (the infusion visit took 45 minutes). Can I report the formalin infusion and the sigmoidoscopy? I cannot find a CPT code for the  formalin infusion.


South Dakota Subscriber
Answer: Report the first encounter with a standard sigmoidoscopy code. For the second encounter, there is no code for formalin infusion, but you may be able to gain payment by reporting an E/M service and a prolonged services code.

On the claim, you should:
   report 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) for the sigmoidoscopy
   report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision making) for the formalin infusion
   report +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient E/M service]) to account for the extra E/M time 
   attach ICD-9 code 569.3 (Hemorrhage of rectum and anus) to 45331, 99212 and 99354 to prove medical necessity for the encounter
   attach ICD-9 code 569.49 (Other specified disorders of rectum and anus; other) to 45331, 99212 and  99354 to prove medical necessity for the visit. Good advice: Since you are reporting a prolonged services code, documentation and diagnoses that prove medical necessity are vital for a healthy claim. Make sure the claim reflects the gastroenterologist's reasons for the formalin infusion and the most specific ICD-9 codes possible. Documentation should also include an explanation as to the necessity of the prolonged physician service, and a detailed description of what service the gastroenterologist provided during the prolonged service time.