“Spotlight on CPT” is focusing on lower endoscopy coding this month. An endoscopy is a medical procedure whereby a flexible tube fitted with a camera and light are inserted into the body via a natural or artificial opening in order to view organs. These procedures may be done on the upper or lower gastrointestinal (GI) tract, and this month, the conversation will center on the lower GI tract endoscopies.
Several criteria are used in order to assign the correct CPT code for these procedures. First, the coding professional has to determine the extent of the scope’s insertion. Lower endoscopies can be categorized by extent of scope insertion as one of the following:
Proctosigmoidoscopy-all of the rectum examined and possibly some part of the sigmoid colon
Sigmoidoscopy-all of the rectum and sigmoid colon examined, and possibly some part of the descending colon
Colonoscopy-entire colon examined (rectum to cecum), and could possibly include the terminal ileum or portion of the small intestine proximal to an anastomosis
Colonoscopy through a stoma-this would include visualization from the colostomy stoma to the cecum, and as with colonoscopy, may include the terminal ileum or portion of the small intestine proximal to an anastomosis
The next criteria that a coding professional must determine is was the procedure simply diagnostic in nature or was it therapeutic. When an endoscopy procedure does not go beyond the splenic flexure, the CPT Manual directs usage of a flexible sigmoidoscopy code. The flexible sigmoidoscopy series of codes also applies when a patient has previously had an ileo-sigmoid or ileo-rectal anastomosis. When the entire colon has been removed and the patient is left with an ileo-anal anastomosis, a pouch endoscopy procedure (44385, 44386) should be coded.
There are many different types of therapeutic endoscopy procedures including dilations, polypectomies, control of bleeding, biopsies, removal of foreign bodies, and insertion of stents to name several. Some, like polypectomies, will be further subdivided by the methodology used for the removal (snare, hot biopsy forceps, etc.). Coding professionals must read the entire source document to obtain the level of detail necessary for the correct code assignment.
Coding with the specific colonoscopy through a stoma code is often overlooked. Coding professionals can easily miss that the insertion of the scope was via the stoma rather than the anus. Again, it is important to carefully read the endoscopy report to discern how the procedure was done. When coding for colonoscopy through a stoma, be mindful that if the defunctionalized rectum or distal part of the colon is also examined, a code for anoscopy, proctosigmoidoscopy, or flexible sigmoidoscopy may also be assigned.
It is not uncommon for conflicting information to exist in these documents. Providers will indicate that they visualized the cecum yet state the billing information should be 45330 for sigmoidoscopy only. It will be necessary to query the provider for clarification if this type of inconsistency is found in the documentation.
Now, light has been shed on lower endoscopy coding.
About the Author
Dianna Foley, RHIA, CCS, CHPS, CDIP is
OHIMA's Education Coordinator. Dianna has been an HIM
professional for over 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati and holds RHIA, CHPS, CDIP and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and is a presenter on coding topics at the national, state, and regional levels. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
