General Surgery Coding Alert

Greet new families for stomal procedures.

If you remember all the changes to the esophagoscopy section in 2014, you’ll have a foretaste of the CPT® 2015 changes for ileoscopy, colonoscopy, sigmoidoscopy, and anoscopy.

That’s because, similar to last year, CPT® makes sweeping changes with the goal of bundling services that surgeons commonly perform together, and providing new, specific codes that accurately describe procedures that are part of current practice.

Resource: Table 1 provides a quick, at-a-glance summary of the CPT® 2015 changes that will impact coding for your surgeon’s endoscopy services. Plus, read on for our experts’ explanations that will help you grasp the scope of changes to the 2015 endoscopy codes. 

Don’t Let ‘Housekeeping’ Confuse You

The large number of new and revised codes in the endoscopy sections can seem overwhelming, but a closer look shows that many of the changes are small editorial revisions for consistency.

The following minor changes standardize wording for clarity:

• Spell out that foreign body removal includes one or more foreign bodies

• Standardize wording by removing “with or without …” and changing the definitions to “including … when performed.”

• Remove “bipolar cautery” from codes for “hot biopsy forceps” procedures. Bipolar cautery may be used as a type of hot biopsy forceps, or it may be used for tumor ablation. “Removing the term from the codes for hot biopsy forceps avoids confusion and emphasizes that the codes are for biopsy removal, not tumor abalation,” explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

• Revise “control of bleeding” endoscopy codes to remove specific method names and state, “any method.” For example, you’ll see the following updated codes: 44391 (Colonoscopy through stoma; with control of bleeding, any method), 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method) and 45382 (Colonoscopy; with control of bleeding, any method).

CPT® 2015 also standardizes stent and ablation codes to indicate that the procedures include pre- and post-dilation and guide wire passage, when performed. Table 1 shows deleted codes that didn’t define these included services, and new codes that do.

Look Ahead

You’ll find many other endoscopy coding changes in CPT® 2015, from new codes that identify decompression as a separate procedure, to new, specific codes for ileoscopy and colonoscopy through stoma. You’ll also notice revisions to the section introductions that clarify how you should use the codes.

Stay tuned: Watch for more “how-to” tips in upcoming issues of General Surgery Coding Alert to make sure that you master endoscopy coding using the revised code set, and capture all the pay you deserve for your practice.

*New wording underlined, deleted wording strike-through

+These codes also delete other specific methods and add any method to the definition.