Gastroenterology Coding Alert

Hint: The type of scope your gastro uses could change the code completely

Picking your lower endoscopy code doesn't have to be rocket science if you zoom in on the right items.

According to Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta, when reporting lower gastrointestinal endoscopic procedures, you need to scan the note for the following facts:

• the approach method

• the length of scope insertion

• what the doctor did through the scope

• the patient's diagnosis.

• the type of scope the doctor used

If you address these five areas before sending out lower GI endoscopy claims, you stand a greater chance at success with payers.

Identify the Approach Method

The initial step in coding a GI endoscopy is identifying whether the procedure is an upper or lower GI endoscopy, says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.
Main difference: With upper GI endoscopies, the physician most often inserts the endoscope in the patient orally. With lower GI endoscopies, the approach is via the anus, Rasmussen says.

Example: If the op note states, "Inserted endoscope anally in Patient X," the procedure would be a lower GI endoscopy.

Place Importance on Scope Length and Type

Once you have decided that a procedure is a lower GI endoscopy, you can begin searching the notes for an indication of how far the gastroenterologist inserted the scope into the patient, Rasmussen says.

For lower GI endoscopy, you need to know the insertion's extent to choose between four separate code sets. Focus on how far the gastroenterologist inserted the endoscope. According to Rasmussen, if the gastroenterologist examines the: 

• anus (up to 5 cm of insertion), you should assign a code from the anoscopy code set: 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 46615 ( ... with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

• anal canal, rectum and the sigmoid colon (6-25 cm), choose a proctosigmoidoscopy code: 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 45321 (... with decompression of volvulus). Red flag: Your gastroenterologist will need to indicate the type of scope he used (such as rigid versus flexible), Parks says.

• entire rectum, sigmoid colon, and/or performs an exam of a portion of the descending colon up to the splenic flexure (26-60 cm), report a sigmoidoscopy code: 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 45339 (... with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

• entire colon from the rectum to the cecum (more than 60 cm) and/or the last portion of the small intestine or terminal ileum, choose a colonoscopy code: 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]) to 45385 (... with removal of tumor[s], polyp[s] or other lesion[s] by snare technique).

Example: A patient's encounter form reads: "Rigid scope inserted anally, 23 cm; examined rectum, sigmoid colon." On the claim, you would choose a code from the proctosigmoidoscopy family (45300-45321), depending on whether the gastroenterologist provides therapeutic or diagnostic service during the procedure.

Error averted: If your gastroenterologist performed this with a flexible scope, you should look for a code in the 45330 family, Parks says.

Weigh Diagnostic Versus Therapeutic

Next, you should check to see whether the gastroenterologist gave diagnostic or therapeutic service.

Why? If you report a diagnostic code (such as 45300, Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) when your gastroenterologist actually administered a therapeutic service, the claim will go through, but you won't receive the amount your claim actually deserves.

Action: When reporting diagnostic services, use the first code in the appropriate lower GI endoscopy family. The initial entry in each of the endoscopic families contains the same wording, "diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)," Rasmussen says. If your gastroenterologist performs a diagnostic lower GI endoscopy, the code you report should contain this phrase.

Example: Suppose the operative notes on a sigmoidoscopy read: "Used washing technique to collect specimen during Dx." On the claim, you would report 45330 for the sigmoidoscopy.

Seek Indented Codes for Therapeutic Service

If, however, the gastroenterologist gave therapeutic service during the procedure, you would choose from the codes below the initial entry. Therapeutic lower GI endoscopy codes appear below the diagnostic code in each endoscopy family. For example, below 45378 for diagnostic colonoscopy, CPT lists several therapeutic colonoscopy codes.

To find the proper therapeutic code, check the operative notes for clues about the procedure the physician performed. Then, use those clues to decide on the proper endoscopic code.

Example: A colonoscopy's op notes state, "Used snare to remove two lesions during procedure." Assign 45385 for the colonoscopy.

Don't miss: Jan Rasmussen, CPC, AGS-GI, ACS-OB, is the presenter of May 22's "Best Practices of Lower GI Endoscopy Coding" audioconference. Sign up or request CD or transcript at http://www.audioeducator.com.