Gastroenterology Coding Alert

Question: My gastroenterologist performed a diagnostic sigmoidoscopy (45330), followed by sigmoidoscopy with control of bleeding (45334). Can I report both codes for this encounter?

Kansas Subscriber

Answer: No. In this case, you can only report 45334 (Sigmoidoscopy, flexible; with control of bleeding [eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). That code already includes (bundles) the work described by 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Because 45330 is a base code, you would report it separately only if the gastroenterologist did not provide any services in the 45331-45345 range. Note that the descriptor for 45330 includes a "separate procedure" designation, meaning that you may not report this diagnostic scope separately with similar procedures.

Caveat: You cannot bill 45334 separately if the physician caused the bleeding during the sigmoidoscopy and then had to control it. In that case, you'll only report 45330. Usually bleeding caused by the procedure will occur as part of a therapeutic maneuver like polyp removal or biopsy.