Gastroenterology Coding Alert

Question: A gastroenterologist in our practice recently treated a patient with a diagnosis of proctitis and continuous rectal bleeding. The gastroenterologist performed a sigmoidoscopy with biopsy during the first encounter. During the second encounter (which took 45 minutes), he infused formalin into the rectum in-office. What CPT^® codes would I use to bill for the formalin infusion and sigmoidoscopy?

Alabama Subscriber

Answer: For the first encounter, a standard sigmoidoscopy code would do. For the second encounter, CPT® assigns no code for formalin infusion, but obviously this is a lengthy procedure taking much more technical time than a standard flexible sigmoidoscopy and requiring separate medical assessment and counseling. You should consider reporting formalin infusion by billing an E/M and a prolonged services code if the documentation is properly completed. On the claim, you should report:

• 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) for the sigmoidoscopy
• Modifier 22 (Increased procedural services) requiring work substantially greater than typically required. If there is no additional payment then you will likely need to appeal and bill this service on a paper claim and include a copy of the report justifying the request for additional payment.,
• K62.5 (Hemorrhage of anus and rectum) linked to 45331,
• K62.7 (Radiation proctitis) linked to 45331-22.

Make sure you submit all appropriate documentation to prove medical necessity for the prolonged services code (-). For example, your documentation should also include an explanation as to the necessity of the prolonged service, and a detailed description of what service the gastroenterologist provided during the prolonged service time. To avoid any hassles with the payer, your claim should reflect the gastroenterologist’s reasons for the formalin infusion and the most specific ICD-10 codes possible.

FYI: Be on the lookout for bundles in 45331. If the GI performed biopsies during a sigmoidoscopy, you would consider them part of the procedure. The anorectal exam, when performed pre-procedure, is also part of the surgical package for 45331.