Gastroenterology Coding Alert

Question: A physician is doing a manual disimpaction of the rectum under anesthesia. What CPT^® code can I use for this? What about disimpaction under no/moderate sedation? Is it appropriate to report CPT^® code 45915 when conscious sedation is used?

Mississippi Subscriber

Answer: Although code 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) is the right code for the procedure, please remember that as per CPT^® Assistant, “CPT^® code 45915 is intended to be reported for fecal impaction or foreign body removals only when performed under general anesthesia. The CPT^® code descriptors that include the phrase “under anesthesia” indicate that the work involved in that specific procedure requires the use of general anesthesia; which, automatically suggests performance in a formal OR setting. Therefore, double check the physician’s notes on the exact setting of the service.

In case of the service being performed in an office setting, the best option to follow is to report a moderate sedation code and an E/M code when reporting this fecal disimpaction scenario. The same coding will apply for a nil/moderate/conscious sedation.

You should report:

• 99214 ( Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components : a detailed history; a detailed examination;  medical decision-making of moderate complexity), for the E/M service, report;
• 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time), for the sedation.

You should attach ICD-10 code K56.49 (Other impaction of intestine) as the primary diagnosis with any other diagnoses the patient may have.

Check this out: There could be another way to report this encounter:

• 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) for the fecal disimpaction;
• Modifier 52 (Reduced services) to 45915 to show that you are billing for moderate sedation, not full sedation;
• Diagnosis K56.49 to 45915 to prove medical necessity for the disimpaction.

However, the payer may deny this code combo since there have been adverse rulings in the past on inappropriate use of modifier 52 and the AMA considers a patient is not “under anesthesia” unless he is in the OR.