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Gastroenterology Coding Alert

Reader Questions:

Consider Base Code Included in 45334

Published on Fri Mar 26, 2010

Question: My gastroenterologist performed a diagnostic sigmoidoscopy (45330), followed by sigmoidoscopy with control of bleeding (45334). Can I report both codes for this encounter? Kansas Subscriber Answer: No. In this case, you can only report 45334 (Sigmoidoscopy, flexible; with control of bleeding [eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). That code already includes (bundles) the work described by 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Because 45330 is a base code, you would report it separately only if the gastroenterologist did not provide any services in the 45331-45345 range. Note that the descriptor for 45330 includes a "separate procedure" designation, meaning that you may not report this diagnostic scope separately with similar procedures. Caveat: You cannot bill 45334 separately if the physician caused the bleeding during the sigmoidoscopy and then had to control it. In that [...]
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