Gastroenterology Coding Alert

Question: What are the limitations of colonoscopy (44388-44397; 45355- 45392)?

Delaware Subscriber

Answer: Be wary if your gastroenterologist performed colonoscopy for the following conditions because you won’t normally be paid for the procedure. These conditions are:

• Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which the colonoscopy may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy
• Acute limited diarrhea
• Hemorrhoids
• Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management
• Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis)
• Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease
• Upper GI bleeding or melena with a demonstrated upper GI source.

If you attempt to submit claims for a colonoscopy for any of these conditions, be sure to have additional documentation that indicates the medical necessity when you submit your records for review by the payer.