Gastroenterology Coding Alert

Question: Our gastroenterologist performed a colonoscopy on a patient with abdominal distention and was concerned about perforation when he found that the patient's abdomen was filling with gas. There turned out to be no bleeding or perforation, but can we report anything other than a diagnostic colonoscopy?

Answer: Look at the intent of the procedure. In your scenario, the gastroenterologist performed a colonoscopy, searched for signs of a perforated colon and found none. That is a diagnostic colonoscopy, which should be reported with 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).

Exception: However, if the gastroenterologist corrected a problem during the colonoscopy (that is, bleeding, polyp removal, submucosal injection, etc.), you would not report a diagnostic colonoscopy. Let's say the doctor found a polyp and performed a snare polpyectomy during the colonoscopy; you should report 45385 ( ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

-- 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.