General Surgery Coding Alert

Question: Our surgeon saw a patient complaining of rectal bleeding in the emergency department. After a level-five E/M, the surgeon personally performed a gastric aspiration (after the nurse was unable to complete the procedure) to determine if the bleeding was from the upper or lower GI tract. How should I code this service?

Washington Subscriber

Answer: The proper code for gastric aspiration is 91105 (Gastric intubation, and aspiration or lavage for treatment [e.g., for ingested poisons]). In addition to intubation, be sure to report the E/M service (99285, Emergency department visit for the E/M of a patient -) with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended to show that the E/M and aspiration were separate services.

Link a diagnosis of 569.3 (Hemorrhage of rectum and anus) to both 91105 and 99285.

-- 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.