Gastroenterology Coding Alert

Question: Operative notes indicate that our gastroenterologist performed a colonoscopy through a created stoma; Is there a specific CPT code I should use for this procedure?

Iowa Subscriber

Answer: Actually, there are several codes to choose from when the gastroenterologist performs a colonoscopy via artificial stoma.

Go back and check the notes to see if the gastroenterologist performed a biopsy, took out a foreign body, or removed a lesion with a specific technique during the colonoscopy. You should also find out whether the stoma was a colostomy (which opens into the colon) or ileostomy (which opens into the small intestine).

Example: Notes indicate a colonoscopy via colostomy; there is no mention of biopsy or lesion removal. Report 44388 (Colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the encounter.

Review the definitions of CPT codes 44380 through 44394 to familiarize yourself with the different types of stoma-related procedures.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.