Gastroenterology Coding Alert

Question: Our gastroenterologist spots a pair of benign polyps in a patient's sigmoid colon, which she accesses via sigmoidoscopy and removes using hot biopsy forceps. There is a slight complication during the removal, resulting in some bleeding at the procedure site. Using cautery, the gastroenterologist stops the bleeding. How should I code this encounter?

Arkansas Subscriber

Answer: You should report a single procedure code for both the polyp removal and the cautery. On the claim, report 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) for the sigmoidoscopy and the cautery, with 211.3 (Benign neoplasm of other parts of digestive system; colon) linked to represent the patient's polyps.

Remember: If the patient was bleeding because of the gastroenterologist's actions during the removal, then you cannot count the blood stop separately. If there is bleeding at a significant and separate site in the sigmoid colon, and you can show that the gastroenterologist did not cause it, you might be able to report a pair of sigmoidoscopy codes: 45333 and 45334 (... with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) with modifier 59 (Distinct procedural service) appended to show the separate nature of the sigmoidoscopies. 

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.