General Surgery Coding Alert

Question: Our surgeon biopsied a suspicious bleeding lesion during an anoscopy procedure. Later the same day, the patient had to return to the operating room due to excessive bleeding, which the surgeon controlled using a plasma coagulator. Is the bleeding control included in the initial service since the return to surgery was on the same day? 

Washington Subscriber

Answer: No, you should not include the return to surgery for bleeding control under a single code for the initial anoscopy with biopsy. 

Although it is true that you should not separately bill for bleeding control that is part of an endoscopy procedure, you should bill for the service when the surgeon performs the work as at a separate session.

In this case, you should report the initial procedure as 46606 (Anoscopy; with biopsy, single or multiple). For bleeding control at a separate session the same day, you should also report 46614 (Anoscopy; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). You’ll need to list 46614 with modifier 59 (Distinct procedural service), because both CPT® and Medicare’s Correct Coding Initiative (CCI) consider 46614 a component of 46606 for the same operative session and anatomic site. 

Avoid: Don’t use the “return to surgery” 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), because the postoperative period doesn’t start until the day after surgery.

Look ahead: When Medicare rolls out the new “X{EPSU}” modifiers in 2015 to replace modifier 59, you would report 46614 in this case with modifier XE (Separate encounter) to indicate that the services did not occur at the same operative session.