Gastroenterology Coding Alert

Question: We performed a colonoscopy at 9 a.m., but the patient returned to our endoscopy lab at 3 p.m. to control a bleeding polypectomy site in the ascending colon. Which code should we report for this? The same gastroenterologist performed both services.

Colorado Subscriber

Answer: You should use code 45382 (Colonoscopy, flexible; with control of bleeding, any method) for the colonoscopy procedure. Append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). This modifier indicates that complications arose that necessitated a return trip to the OR.

Control of bleeding is an integral component of endoscopic procedures and is not separately reportable. If it is necessary to repeat an endoscopy to control bleeding at a separate patient encounter on the same date of service, the code for endoscopy for control of bleeding is separately reportable with modifier 78 indicating that the procedure required return to the operating room (or endoscopy suite) for a related procedure during the postoperative period.

Note: If the patient comes in bleeding on a different calendar date, you don’t need the modifier, since the endoscopy is a zero-day global service.

Careful: You should not use modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) and 77 (Repeat procedure or service by another physician or other qualified health care professional) because these describe a situation in which the physician reports the same procedure twice. In this case, the initial colonoscopy was different from the second colonoscopy, which the physician performed to control bleeding.

Along the same lines, you should not report modifier 73 (Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia), because the physician concluded the first procedure and had to go back for a second.