General Surgery Coding Alert

Question: How can I quickly determine which lower gastrointestinal endoscopy code set I should code from? For instance, what differentiates a sigmoidoscopy from a colonoscopy?

Maryland Subscriber

Answer: Choosing the right lower GI endoscopy code depends on how far the physician inserted the endoscope. For this reason, you-ll want to be sure that your physician knows the importance of documenting the extent of the endoscopic examination and the anatomical landmarks he viewed.

For quick reference, when the physician examines:

• the anus (up to 5 cm of insertion), you should choose from the anoscopy code set: 46600, Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) to 46615, ... with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
• the anal canal, rectum and the sigmoid colon (6-25 cm), you should select a proctosigmoidoscopy code: 45300, Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) to 45321, ... with decompression of volvulus.
• the entire rectum, sigmoid colon, and/or performs an exam of a portion of the descending colon up to the splenic flexure (26-60 cm), you will look to the sigmoidoscopy code set: 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) to 45339, ... with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
• the entire colon from the rectum to the cecum (more than 60 cm) and/or the last portion of the small intestine or terminal ileum, you may choose a colonoscopy code: 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) to 45385, ... with removal of tumor(s), polyp(s) or other lesion(s) by snare technique.

Example: A patient's encounter form reads: -Scope inserted anally, 23 cm; examined rectum, sigmoid colon.- On the claim, you would choose a code from the proctosigmoidoscopy family (45300-45321), depending on whether the physician provides therapeutic or diagnostic service during the procedure.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.