Gastroenterology Coding Alert

Question: After performing a level three E/M for an established patient, the gastroenterologist decides to perform colonoscopy. Notes indicate "colonoscopy with volvulus reduction, decompression, and placement of colon decompression tube. What type of colonoscopy is this? New York Subscriber Answer: All of the services listed in your procedure note are included in the base colonoscopy code. On the claim, report the following: • 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for the colonoscopy • 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M • modifier 25 (Significant, separately identifiable evaluation and management service by the same [...]