Gastroenterology Coding Alert

Question: The gastroenterologist performs expanded problem focused interval history and exam on a hospital inpatient. She then performs an anorectal exam under anesthesia, a flexible sigmoidoscopy, and three biopsies of the mucous membrane. How many procedure codes can I report for this scenario?

Kansas Subscriber

Answer: A single procedure code represents all of the non-E/M services in this encounter. On the claim, report the following:

• 45331 (Sigmoidoscopy, flexible;with biopsy, single or multiple) for the sigmoidoscopy

• 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same  physician on the same day of the procedure or other service) appended to 99232 to show that the E/M and the sigmoidoscopy were separate services.

The 45331 code covers a lot of ground. Since the gastroenterologist performed the biopsies during the sigmoidoscopy, they are part of the procedure. The anorectal exam, when performed pre-procedure, is also part of the surgical package for 45331.