General Surgery Coding Alert

Look for relation to splenic flexure.

You read about screening colonoscopies last month in “Payer, Risk, and Findings Drive Colonoscopy Code Choices” (General Surgery Coding Alert Vol. 16, No. 6), but do you know how to handle diagnostic colonoscopy cases?

Follow our experts’ advice for this one simple case, and you’ll be ready to make sure you report the proper diagnosis and procedure codes every time. 

Scenario: A patient presents with iron deficiency anemia and a positive fecal occult blood test. The surgeon performs a colonoscopy advancing through the rectum and finds multiple small, vascular malformations near the cecum, noting two lesions that are actively bleeding. The surgeon advances an instrument to seal the lesions and halt bleeding using an Nd:YAG laser. Based on the findings, the surgeon identifies a diagnosis of angiodysplasia.

Look at the following steps and you’ll make sure to choose the correct coding and avoid a double-dipping error you might be tempted to make.

Step 1: Show Medical Necessity

You should use the presenting diagnoses to indicate medical necessity for a diagnostic colonoscopy. Report the following two codes based on the clinical diagnosis prior to the colonoscopy:

• 280.9 — Iron deficiency anemia unspecified
• 792.1 — Nonspecific abnormal findings in stool contents.

Reporting the clinical diagnosis shows medical necessity for the colonoscopy, and ensures that the coverage is based on the need for a diagnostic test, not a screening exam, which would subject you to frequency and other coverage rules. 

Report findings: Because the surgeon describes actively-bleeding lesions that he identifies as angiodysplasia, you should also assign 569.85 (Angiodysplasia of intestine with hemorrhage). 

Step 2: Choose the Proper Endoscopy Group

How far your surgeon advances the endoscope is the key to getting yourself in the proper group of codes. 

CPT® organizes the endoscopy codes into three groups, as follows:

• Proctosigmoidoscopy — Involves examination of rectum and sigmoid colon. The procedure typically involves a rigid scope (45300-45327).
• Sigmoidoscopy — Includes exam of the rectum, sigmoid colon, and possibly a portion of the descending colon (45330-45345).
• Colonoscopy — Incorporates assessment of the entire colon from the rectum to the cecum, and possibly the terminal ileum (45378-45392).

“In this case, the note indicates that the surgeon proceeded to the cecum, so you should choose a colonoscopy code,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. 

Step 3: Look for Procedure Beyond Diagnosis

The surgeon initiated the procedure as a diagnostic colonoscopy (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). 

After identifying angiodysplasia lesions, the surgeon then advances an Nd:YAG laser and cauterizes the lesions to control bleeding. That means the surgeon performed 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). 

Caution: You should not report both 45378 and 45382. “Surgical endoscopy always includes diagnostic endoscopy,” states CPT® instruction. Always report the most comprehensive procedure, which is 45382 in this case.