Gastroenterology Coding Alert

Question: A new patient with anal cancer reported to the office for a diagnostic sigmoidoscopy. Operative notes indicate that staff provided a level-four E/M service prior to sigmoidoscopy. Can we code for both services?

Colorado Subscriber

Answer: If you prove medical necessity for a level-four E/M service and a sigmoidoscopy -- and provide enough documentation to show that the services were separate -- you should receive payment. Many practices provide separate E/M services when performing minor surgeries, but not every office reports two codes when they can.

On your claim, you should:

• report 45330 (Sigmoidoscopy, flexible; diagnostic,-with or without collection of specimen[s] by brushing-or washing [separate procedure]) for the sigmoidoscopy

• report 99204 (Office or other outpatient visit for-the evaluation and management of a new patient, which requires these three key components: a-comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity)-for the E/M service

• attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other-service) to 99204 to show that the E/M service was not part of the sigmoidoscopy

• attach ICD-9 code 154.3 (Malignant neoplasm of-rectum, rectosigmoid junction, and anus; anus, unspecified) to 99204 and 45330.

Heads up: In addition to the above codes, make sure you include documentation that proves the distinct and separate nature of the sigmoidoscopy and the E/M service. In general, this means that the surgical procedure will have documentation that is separately identified from the patient visit.