Gastroenterology Coding Alert

Question: A patient was admitted to my center for a colonoscopy. Sedation was started, but the patient started vomiting before he was brought to the procedure room, and the gastroenterologist decided to cancel the procedure. The patient remained in the center for an additional hour. The patient was given medication and attended to by a nurse. Should this service be reported? Which CPT and diagnosis codes should I use?

Utah Subscriber
Answer: The facility can bill for the procedure with colonoscopy code 45378 and modifier -74 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia).
 
Since medication was administered to the patient, it seems likely that some E/M services were provided by the gastroenterologist, which would be reported with an E/M code. You would bill an established patient office or other outpatient visit (99211-99215). The level of history, examination and medical decision-making performed by the gastroenterologist during both the preoperative and recovery period would determine the level of E/M service reported. You cannot bill separately for services provided by the nurse.
 
Because the only symptom you mention is vomiting (787.03), that should be the primary diagnosis. If you want to list V64.1 (Surgical or other procedure not carried out because of contraindication), put it as a secondary diagnosis. Most insurers will not reimburse for a service when a V code is the primary diagnosis.
This month's Reader Questions were answered by Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania Department of Medicine; and Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice.