Gastroenterology Coding Alert

Question: How should I report sigmoidoscopy with tumor removal, followed by control of bleeding at a separate location within the sigmoid colon?


Michigan Subscriber


Answer: Depending on the method of removal, you should report 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s] or other lesions[s] by hot biopsy forceps or bipolar cautery) or 45338 (-with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) for the tumor removal, and 45334 (-with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the control of bleeding.

In addition, you should append modifier 59 (Distinct procedural service) to 45333 or 45338 to differentiate it from 45334 at a different location. If you leave off 59, the payer will bundle the procedures based on National Correct Coding Initiative guidelines.

Although you may report both 45333 or 45338 and 45334 in this case, the -multiple endoscopy- rule applies. This means that the payer will reimburse for the highest-paying procedure at 100 percent of the usual fee rate but reduce the value of the secondary procedure by an amount equal to payment for the -base- endoscopic procedure. The payer's thinking in this case is that because both procedures include a basic approach, you should only be paid for that approach once.

For example: You will receive full value for the control of bleeding (2.73 physician work relative value units, or about $104 on average for Medicare payers). For the sigmoid with tumor removal, you will receive the standard fee (1.79 work RVUs) minus the value of the endoscopic base code for both procedures (45330, -diagnostic-, valued at 0.96 work RVUs), or 0.83 RVUs (about $32 on average for Medicare payers).