General Surgery Coding Alert

Question: During a colonoscopy, the surgeon noted “a fungating circumferential bleeding mass of malignant appearance in the proximal rectum and distal sigmoid colon at 15 cm from the anus. The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Cold forceps biopsies were performed. Four 1 ml india ink injections were successfully applied for tattooing.” Should I bill this as a colonoscopy with biopsy and tattoo, or a flexible sigmoidoscopy with biopsy and injection?

Kentucky Subscriber

Answer: You should not bill a colonoscopy unless the surgeon passed the scope to the splenic flexure (at least), which did not occur in this example. That means you should not report a colonoscopy code (such as 45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), regardless of the surgeon’s original intent.

Instead, you’ll have to bill this as a proctoscopy or sigmoidoscopy, depending on what the surgeon documents in the op note. 

For instance: You might report this procedure as 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) and 45335 (... with directed submucosal injection[s], any substance).