General Surgery Coding Alert

Don’t unbundle ultrasound, aspiration.

When your surgeon preforms certain lower GI tract procedures with many steps, knowing which service components require separate codes can be confusing.

Problem: If you individually code too many of the parts of a multi-step procedure you risk “unbundling” and facing fraud charges. Conversely, you don’t want to leave off legitimate separate work and risk leaving money on the table.

Do this: Study the following surgical case, then see how our experts break it down for proper reporting.

Here’s the Case

A 57-year-old male with a diagnosis of anemia presented with frank red blood in the stool. The surgeon scheduled a flex sigmoidoscopy for a later date.

The day of the procedure, the surgeon advances the flexible sigmoidscope and examines the inner part of the anus, rectum and sigmoid colon up to the splenic flexure (a bend in the colon at the junction of the transverse and descending segments of the colon. During the exam for abnormal tissue or lesions, the surgeon notes enlarged perirectal lymph nodes, and proceeds to perform an endoscopic ultrasound (EUS) of the site. Under ultrasound guidance, the surgeon inserts a fine gauge needle through the scope, and aspirates a fluid sample consisting of cells from the area of the enlarged lymph nodes. This procedure is a fine needle aspiration (FNA).

Here’s the Coding

“You should code the procedure as 45342 (Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s]),” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr.

Although CPT^® provides other sigmoidoscopy codes such as 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) or 45341 (Sigmoidoscopy, flexible; with endoscopic ultrasound examination), code 45342 is the only choice that describes all parts of the procedure that your surgeon performs.

Differentiate colonoscopy: According to CPT^® instruction, you should report flexible sigmoidoscopy if your surgeon doesn’t advance the scope beyond the splenic flexure. Based on the operative note, you should not bill this case with a colonoscopy code, such as 45392 (Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s], includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures).

Here Are the Pitfalls

Despite the 45342 code descriptor that perfectly describes the procedure from the op note, several misconceptions may crop up that lead you astray when coding a case like this. Here are some pitfalls that other coders have stumbled on that you should be sure to avoid:

Skip over base code: Sometimes coders want to separately bill the diagnostic examination and the sampling or treatment procedure code. Especially in this case where the surgeon started with a flexible sigmoidoscopy and added the EUS FNA based on endoscopy findings, you might be tempted to report 45341 and 45342. But that would constitute unbundling of an integral procedure. “The therapeutic endoscopy procedure always includes the base code for the diagnostic endoscopy,” Joy explains.

FNA included: Nor should you separately report an FNA code such as 10022 (Fine needle aspiration; with imaging guidance) with the EUS sigmoidoscopy. Code 45342 includes the FNA procedure.

Resist radiology: Although the 45342 code definition doesn’t state that it encompasses all the radiology services, you should not separately report any of the following codes with 45342:

• 76872, Ultrasound, transrectal
• 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
• 76975, Gastrointestinal endoscopic ultrasound, supervision and interpretation.

Both a CPT^® text note and Correct Coding Initiative (CCI) edits indicate that the 45342 procedure includes the services described by codes 76872, 76942, and 76975.