Gastroenterology Coding Alert

Question: A patient presented with intermittent bright red blood in the stool, and the gastroenterologist performed an anoscopy to evaluate the patient’s condition. Which code applies?

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Answer: The anoscopy is a diagnostic examination typically performed to confirm that active bleeding is from hemorrhoids (for instance, 46600, Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

What happens: During an anoscopy, your gastroenterologist uses a short, rigid, hollow tube (anoscope) that may contain a light source to examine the last 5 to 10 cm of the colon, or anal canal. Applicable anoscopy codes are 46600-46615. The doctor often performs an anoscopy in the office setting without sedation.

Note: If your gastroenterologist performs an office visit that is unrelated to the anoscopy, you can report that using the office visit codes (99202-99215). Apply the diagnosis, which may be the same or different, that supports the separate office visit, and add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Be sure to maintain the documentation that can support the separate nature of the E/M service.