General Surgery Coding Alert

Question: Our surgeon performed a colonoscopy with polyp removal 45385, and discharged the patient. The patient returned later the same day complaining of bloody stool. The surgeon then did a second colonoscopy to control bleeding. Should we separately code the second colonoscopy?

Indiana Subscriber

Answer: Because the surgeon performed the bleed control in a separate procedural session, you can bill for it in addition to the primary procedure.

Do this: Report the initial colonoscopy as 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Then report the second procedure with the bleeding control using 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). You must append 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) to 45382.

Correct coding initiative (CCI) guidelines in the National CCI Policy Manual (effective Jan. 1, 2012) provide the following instructions:

"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."