General Surgery Coding Alert

Question: Our surgeon removed three polyps using hot biopsy forceps during a proctosigmoidoscopy. During the procedure, the patient began bleeding. The surgeon stopped the bleeding using a plasma coagulator. Can I report both procedures?


Missouri Subscriber


Answer: Before deciding on one or two proctosigmoidoscopy codes, you must ask yourself: "Did the surgeon cause the bleeding?"

Check out both answers to that question:

If you answered "yes": If the surgeon caused the bleeding during the polyp removal (and it sounds as if your surgeon may have), you cannot report both proctosigmoidoscopies. On your claim, report only 45315 (Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps or other lesions by hot biopsy forceps, bipolar cautery or snare technique) for the polyp removal.

If you answered "no": If the bleeding was at a significant and separate site in the rectum/sigmoid colon - and your surgeon's actions had nothing to do with the bleeding - you may be able to report the control-of-bleeding proctosigmoidoscopy as well. If your documentation proves two separate sites, this could be a two-code claim:
  Report 45315 for the proctosigmoidoscopy with polyp removal.
  Report 45317 (... with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the procto-sigmoidoscopy with control of bleeding. In this case, you should attach modifier -59 (Distinct procedural service) to 45317. The modifier shows the payer that the surgeon treated two separate injuries. Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.