Gastroenterology Coding Alert

Gastroenterology practices are often stymied as to how to report a colonoscopy or other endoscopy performed through a stoma because those procedures are listed in the small bowel and stomal subsection (44360-44397) of the ,.CPT manual and not the primary colonoscopy through rectum subsection (45378-45387). And, there is often confusion as to whether it is appropriate to report separately a colonoscopy through stoma and flexible sigmoidoscopy or a combination of endoscopy through stoma procedures that could be performed during the same session.
 
Endoscopies through a stoma, which is an opening in the wall of the abdomen, are performed on patients who have had a colectomy to remove all or part of their colon, according to Donald Walters, MD, a gastroenterologist in Butler, Pa., and a member of the American Society of Gastrointestinal Endoscopy's practice management committee. Either the ileum of the small bowel or the large intestine is looped through the stoma so the contents from the intestine can drain out into a sealed pouch.
 
The primary endoscopy through stoma procedures are as follows:
 
1. Ileoscopy through stoma (44380, ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing [separate procedure]) is an endoscopy of the small intestine through an opening in the surface of the abdomen. The patient has previously had a colectomy that removed the entire colon. In addition to the colectomy, the patient has had an ileostomy, where the ileum of the small bowel is attached to the stoma.
 
2. Colonoscopy through stoma (44388, colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) is an endoscopy of the large intestine through an opening in the surface of the abdomen. The patient has previously had a colectomy that removed part of the colon. In addition to the colectomy, the patient has had a colostomy, where the large intestine is attached to the stoma.
 
3. A third variation (44385, endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) is for patients who have had an ileal pouch reconstruction. In these cases, the ileum is used to create a new rectum or intra-abdominal reservoir below the stoma.
 
 
Some coders are uncertain about whether an ileoscopy or a colonoscopy through stoma was performed by the gastroenterologist or whether the colonoscopy was through a stoma or the rectum. It is the gastroenterologist's responsibility to state clearly in the operative report whether an ileoscopy or colonoscopy through stoma was performed, says Walters, who uses those exact phrases in his operative reports to indicate what occurred.

 
It is not unusual for a flexible sigmoidoscopy to be performed during the same session as a colonoscopy through stoma. After a colostomy, the patient's colon is divided into two parts: one that runs from the proximal colon to the stoma, and the other that runs from the site of resection through the remaining large intestine to the rectum. A colonoscopy through stoma only looks at that proximal portion of the colon, starting from the level of the stoma. About seven out of 10 times" however our gastroenterologists will want to look at the distal colon and rectum with a flexible sigmoidoscopy to make sure there aren't any polyps there " says Linda Parks MA CPC lead coder at Atlanta Gastroenterology Associates a 23-physician practice.
 
To report this combination of procedures Parks recommends using 44388 and 45330 (flexible sigmoidoscopy). Modifier -59 (distinct procedural service) should be attached to the flexible sigmoidoscopy code (the lesser-valued procedure) to indicate that it is a distinct and separate procedure. Because these two procedures do not have the same endoscopic base code the multiple surgeries payment rules apply. Reimbursement for the colonoscopy through stoma will be 100 percent of the allowable fee while payment for the flexible sigmoidoscopy will be 50 percent of the allowable fee or about $27 in a facility setting.
 
While less common it is also clinically possible to perform a colonoscopy and colonoscopy through stoma during the same session. "It is possible to do a colonoscopy if the endoscope is advanced proximal to the splenic flexure " Parks says. "In almost all cases however the splenic flexure has probably been removed and you have to report a flexible sigmoidoscopy instead."
 
To report a colonoscopy and colonoscopy through stoma performed during the same session Parks would bill 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]) and 44388. Modifier -59 should be attached to the colonoscopy through stoma code (the lesser-valued procedure) to indicate that it is a distinct and separate procedure. Because these two procedures are not from the same endoscopic family the multiple-surgeries payment rules apply. Reimbursement for the colonoscopy will be 100 percent of the allowable fee while payment for the colonoscopy through stoma will be 50 percent of the allowable fee or about $85 in a facility setting.

 
The same Correct Coding Initiative (CCI) edits and multiple endoscopy rules that apply to the family of colonoscopy codes (45378-45387) apply to the family of codes for colonoscopy through stoma (44388-44397). Multiple procedures such as two or more methods of removing a polyp can be performed during the same session. For example polyps could be removed by both the snare technique (44394) and hot biopsy forceps (44392) during a colonoscopy through stoma.
 
These two codes are not bundled together as CCI edits and can be reported separately. Parks recommends adding modifier -59 to 44392 (the lesser-valued procedure) to indicate a distinct and separate procedure. Because these codes have the same endoscopic base code (44388) the multiple-endoscopies payment rules apply and reimbursement for the removal by snare technique will be 100 percent of the allowable fee. Payment for the removal by hot biopsy forceps will be about $56 or the difference between the allowable fee for the procedure and its endoscopic base code.
 
The control-of-bleeding code (44391) is bundled into colonoscopy through stoma polypectomy codes (44392-44394) just as 45382 (colonoscopy with control of bleeding any method) is bundled into the polypectomy codes (45383-45385). To report a polyp removal by snare technique (44394) and a control-of-bleeding (44391) that were performed separately during the colonoscopy through stoma modifier -59 should be attached to the control-of-bleeding code because it is listed as the component code in the CCI edits.
 
Because these codes have the same endoscopic base code reimbursement for the removal by snare technique will be 100 percent of the allowable fee because this is the higher-valued procedure. Reimbursement for the control-of-bleeding procedure will be approximately $77 or the difference between the allowable fee for the procedure and its endoscopic base code.
 
Note: The relative value units for colonoscopy for stoma are different from those for colonoscopy through the rectum. With the latter the control of bleeding is the higher-valued procedure and the one that would be reimbursed at 100 percent.

 
Several endoscopy through stoma procedures don't have specific CPT codes. Although there are codes for ileoscopy with biopsy and stent placement there is no code for ileoscopy with control of bleeding. There is also no code for ileoscopy with removal of polyps which Walters says might be performed on Crohn's disease patients who have small bowel polyps.
 
On the colonoscopy through stoma side gastroenterologists may use a balloon guide wire or bougie to dilate a stoma that has narrowed due to ischemia (decreased blood supply to the stoma) or tumor growth Walters says. But there is no specific code for a colonoscopy through stoma with dilation.
 
The best way to bill these procedures that have no CPT code is to report the unlisted intestine code (44799) in addition to the primary endoscopy code Parks says. A colonoscopy through stoma with dilation would be reported with 44388 and 44799 for example. An ileoscopy with control of bleeding or polyp removal would be reported with 44380 and 44799. When reporting unlisted-procedure codes a copy of the operative report and a separate statement describing the steps taken in the unlisted procedure should accompany the claim. The separate statement should include the typical time taken to complete the procedure and mention a listed service that is its closest equivalent.