Louisiana Subscriber
Answer: There are several details you’ll need from the procedure report before you can select the most accurate code for an anorectal biopsy.
First, you would consider the instrument your gastroenterologist used to obtain the biopsy. For instance, if the gastroenterologist used an anoscope to obtain a surface biopsy, you would report 46606 (Anoscopy; with biopsy, single or multiple). If they used a proctosigmoidoscope, then you should instead report 45305 (Proctosigmoidoscopy, rigid; with biopsy, single or multiple).
It’s also likely that your gastroenterologist would perform an anorectal biopsy during a flexible sigmoidoscopy (45331, Sigmoidoscopy, flexible; with biopsy, single or multiple) or during a colonoscopy (45380, Colonoscopy, flexible; with biopsy, single or multiple). In these cases, you won’t report a separate code in addition to the code for the sigmoidoscopy/ colonoscopy, since these include the biopsy in the descriptor.
Additionally, you should consider the biopsy’s depth when performing anorectal biopsy. A surgical procedure for a deeper biopsy would call for coding 45100 (Biopsy of anorectal wall, anal approach (eg, congenital megacolon)). This biopsy of the anorectal wall from an anal approach is also known as “suction biopsy.”
