General Surgery Coding Alert

Question: Our surgeon used a rigid scope to rule out colitis for a patient complaining of abdominal cramps, blood in the stool, diarrhea, and frequent bowel movements. The surgeon examined the rectum and a portion of the descending colon and took a biopsy. How should we code this?

South Carolina Subscriber

Answer: The best code selection for the work you describe is 45305 (Proctosigmoidoscopy, rigid; with biopsy, single or multiple).

The clues that lead to this code selection include the type of scope (rigid versus flexible) and how far the surgeon advances the scope (beyond the rectum, but not through the entire descending colon).

Those two factors would rule out coding the procedure as a sigmoidoscopy, such as 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple), which involves a flexible scope and advances through the entire descending colon and perhaps even a portion of the sigmoid colon.

The same factors rule out coding the procedure as an anoscopy, such as 46606 (Anoscopy; with biopsy, single or multiple), which does not involve any examination of the colon.