General Surgery Coding Alert

Question: Which code should we use for a case when the surgeon performs an anorectal biopsy?

Louisiana Subscriber

Answer: You need to consider several details from the op report before you can select the proper code for an anorectal biopsy.

Scope: If the surgeon takes a biopsy as part of a scope procedure, you should choose the appropriate code base on the type of scope, as follows:

• 46606 (Anoscopy; with biopsy, single or multiple)
• 45305 (Proctosigmoidoscopy, rigid; with biopsy, single or multiple)
• 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple)
• 45380 (Colonoscopy, flexible; with biopsy, single or multiple)

You can see that all of these scope codes include the biopsy, so you should not report an additional code for the biopsy itself.

Caveat: You also need to consider the approach and biopsy’s depth when performing anorectal biopsy. A surgical procedure for a deeper biopsy would call for coding 45100 (Biopsy of anorectal wall, anal approach (eg, congenital megacolon)). This biopsy of the anorectal wall from an anal approach is also known as “suction biopsy.”