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General Surgery Coding Alert

Reader Questions:

Not Every Component Is Separately Reportable

Published on Sat Nov 28, 2009

Question: One of our physicians is doing the following procedure on a patient: "Exam under anesthesia, sigmoidoscopy, and a dye test for vaginal fistula." The dye test is what has me stumped. My physician explained to me that they soak dye in gauze and insert it into the vagina to show if the patient has a fistula or not. How should I code the dye test? Maryland Subscriber Answer: Simply putting a dye-soaked gauze in the vagina is not going to be separately codeable. Assuming that, as part of the sigmoidoscopy, the surgeon is using the dye and then looking to see if the dye seeps through the fistula into the colon, there isn't something separately codeable. Therefore, you will just report the code for the sigmoidoscopy procedure, such as 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).
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