General Surgery Coding Alert

Question: A Medicare patient returned to the endoscopy lab to control a bleeding polypectomy site in the ascending colon after a colonoscopy performed the preceding day. The same physician performed both procedures. Which is the best code and modifier combination to report this?

Virginia Subscriber

Answer: You should use code 45382(Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the colonoscopy procedure. Combine it with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). This modifier indicates that complications arose that necessitated a return trip to the OR.

Control of bleeding is an integral component of endoscopic procedures and is not separately reportable. If it is necessary to repeat an endoscopy to control bleeding at a separate patient encounter on the same date of service, the HCPCS/CPT® code for endoscopy for control of bleeding is separately reportable with modifier 78 indicating that the procedure required return to the operating room (or endoscopy suite) for a related procedure during the postoperative period.

Careful: You should not use modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure or service by another physician or other qualified health care professional) because these describe a situation in which the physician reports the same procedure twice. In this case, the initial colonoscopy was different from the second colonoscopy, which the physician performed to control bleeding.

Along the same lines, you should not report modifier 73 (Discontinued out-patient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia), because the physician concluded the first procedure and had to go back for a second.