General Surgery Coding Alert

Question: An established 64-year-old patient complaining of rectal pain and abdominal cramps reports to the surgeon. During a level-four E/M service, the surgeon discovers a foreign body (FB) in the colon. The surgeon then removes the FB via flexible sigmoidoscopy. Due to the patient's anxiety and pain, the surgeon provides 26 minutes of moderate sedation during the procedure. Can we report the sedation separately?

Massachusetts Subscriber

Answer: You cannot report moderate sedation separately in this case. CPT bundles moderate sedation into all of the colonoscopy codes, so your claim cannot include 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time).

How can you tell? You can easily check if moderate sedation is bundled into a procedure code: Simply look up the code in your CPT manual. If the code has the "8" symbol next to it, you cannot report moderate sedation in addition to that code. The code for colonoscopy with FB removal (45379) has such a mark next to it.

In this case, then, you should report:

- 45332 (Sigmoidoscopy, flexible; with removal of foreign body) for the colonoscopy

- 936 (Foreign body in intestine and colon) linked to 45332 to represent the FB

- 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M

- 936 linked to 99214 to represent the FB

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99214 to show that the E/M and FBR were separate services.