Gastroenterology Coding Alert

Question: A patient presented complaining of intermittent bright red blood in the stool, and the gastroenterologist believes persistent hemorrhoids may be causing the condition. The gastroenterologist performs an anoscopy to evaluate the patient’s condition. What’s the correct coding for this?

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Answer: To confirm that the active bleeding is from hemorrhoids, your gastroenterologist will typically perform a diagnostic examination (the anoscopy), which you’ll code using 46600 (Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

Procedure refresh: 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 found in the endoscopy section of CPT^® (46600-46615). A doctor will often performs an anoscopy in the office setting without sedation.

Reminder: If the patient presented for reasons not having to do with the blood in stool, coding will likely be a little different. If your gastroenterologist performs an office visit that is unrelated to the anoscopy, you can report that using the appropriate evaluation and management (E/M) codes, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded). 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.