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Gastroenterology Coding Alert

Reader Questions:

Discover Cause Before Coding Control of Bleeding

Published on Tue Jul 28, 2009

Question: Our gastroenterologist spots a pair of benign polyps in a patient's sigmoid colon, which she accesses via sigmoidoscopy and removes using hot biopsy forceps. There is a slight complication during the removal, resulting in some bleeding at the procedure site. Using cautery, the gastroenterologist stops the bleeding. How should I code this encounter? Arkansas Subscriber Answer: You should report a single procedure code for both the polyp removal and the cautery. On the claim, report 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) for the sigmoidoscopy and the cautery, with 211.3 (Benign neoplasm of other parts of digestive system; colon) linked to represent the patient's polyps. Remember: If the patient was bleeding because of the gastroenterologist's actions during the removal, then you cannot count the blood stop separately. If there is bleeding at a significant and separate site in [...]
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