General Surgery Coding Alert

Question: Our surgeon performed a colonoscopy on a patient who had a previous sigmoid colectomy. The surgeon biopsied four polyps, and performed a dilation by balloon due to the anastomosis stricture. Can we code both the biopsy and the balloon dilation?

Texas Subscriber

Answer: Yes, you can bill for both the balloon dilation and the polyp removal, because the two procedures are medically necessary to address two distinct conditions.

Report the following two codes to capture the work your surgeon performed:

• 45380 -- Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
• 45386 -- ... with dilation by balloon, 1 or more strictures.

You should link the balloon dilation to a stricture diagnosis (e.g., 568.0, Peritoneal adhesions [postoperative], [postinfection]), and the biopsies to a polyp diagnosis (e.g., 211.3, Benign neoplasm of colon).

CCI clear: Before reporting codes like this together, you should always check Correct Coding Initiative (CCI) or other edit packages that your payers use to define proper coding. In this case, CCI doesn't bundle 45380 and 45386. That means you can report the codes together with no restriction if the medical record indicates necessity for both procedures, and the op report documents that the surgeon carried out both procedures.

Expect reduced pay: Because your surgeon performed two scope procedures, you can expect the multiple endoscopy payment reduction to apply to the fees you'll receive. This calculation takes out the base shared endoscopy fee (diagnostic colonoscopy, in this case) from the second procedure. The payment reduction avoids duplicate payment for the shared portion of the procedure.