Gastroenterology Coding Alert

Question: A patient, referred by his physician, presents to our office for a diagnostic colonoscopy. Our gastroenterologist sees this patient for the first time, and after answering some patient questions during a brief introduction, decides to perform a diagnostic colonoscopy with brushing. Should I report an E/M code, particularly on the time the gastroenterologist spent with the patient before the colonoscopy? Nevada Subscriber

Answer: An E/M code is inappropriate for this encounter. Instead, you should report 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]) for the service.

Here's why: The pre-service time spent by the gastroenterologist on a patient on a scheduled procedure is almost always included in the procedure code, regardless whether the patient has been to your practice before or not.