Gastroenterology Help!!


Clinton Twp, MI
Best answers
Hello, I am new to this specialty. Does anyone have any resources for documentation guidelines/requirements for Anoscopies, Proctosigmoidoscopies, etc done in the office? I have been looking for hours and am unable to find anything concrete directly related to these type of procedures. Thank you in advance.
Here are some CPT manual pages 315 to 344. Keep in mind there are differ areas of the intestines or hemorrhoids dx K64 (external and internal ) in which provider should tell you which are removing the polyp from or rectum problems notice. Polyps if removed usually see dx D12-D13 blocks. Carcinom in situ see Dx D01,Cancer see dx C16-C18 in gastro areas. Use the family HO or personal HO of Z codes last on claim if applicable. Check out Dx blocks Z80, Z86 and Z85 for pt histories. Encounter first listed dx Z12.11 if a screening for colonoscopy due per age or payer .Medicare insurance says add modifier 32 to a colonoscopy done since mandated. If pt has gastro problem then provider does diagnostic colonoscopy put dx problem they have first dx on claim (such as dx R19. 7 K59, K57, K92 as examples). Then can add dx Z13.810--Z13.812 or dx Z12.11. Also if provider starts colonoscopy and has to stop due to much fecal matter or other problem add modifier 53 or 52 and send in with med record documentation.
When bill a discovered polyp put where it is found in the colon do not just add K63.5 dx. Anesthesia is usually not billed with colonoscopies(bundled in) If get polyps sent to lab check results ensure not cancerous. Labs used for this are 88305 and fecal test done are billed later when get results Lab code for take home fecal test are 82270 87177 87045 link with dx Z12.11 with these labs. Understand differ between colonoscopy CPT 45378 -scoping view thru rectum vs a EGD CPT 43235 check stomach and throat area. Also can be done at same time. Gastro dx for stomach could be to linked with EGD procedure dx K21.9 K59, and ending dx Z13.81 on claim
Well hope this helped you a little bit
Lady T
Thank you !! Do you know of any specific documentation requirements that the doctor has to document in order to bill an anoscopy or proctosigmoidoscopy? My docs are saying "Anoscopy: grade II internal hemorrhoids". Is that enough to code? If not, what else should be documented? Is there something written somewhere that I can take to my docs for educational purposes?
Hi Sugar joe
Yes document description of rectum procedure done on each patient. List the lubricant, insertion, what notice and why did the anoscopy or proctosigmoidscopy need to be completed. This can be done in office in a few minutes. Also get pt sign consent for this procedure. If ofifce visit for another med problem like chronic DM or CHKD or new problem rash or bruise...if provider talks to pt can do this as additional procedure on same day. Add modifier 25 on office Ev Mgnt code then add rectum peek in process. If notice hemorrhoids or anything else put in notations. If do biopsy, brushing, snare hot biopsy or remove growth send to lab ...document it all. Also Medicare codes are G0121 and G0105. G0105 is for high risk pts.

Here is an example of anoscope documentation......
After discussion of prior cytology/biopsy findings and today’s planned procedure, signed informed consent was given to proceed. The patient was placed in the LLD position. The anal canal was anesthetized with 2% lidocaine gel and an anoscope was inserted. The anal canal and transition zone were stained with a 4x4 gauze sponge soaked in acetic acid (vinegar) inserted through the anoscope as the anoscope was removed. After several minutes, the gauze was removed and the anoscope was reinserted. 360 degrees of the SCJ*was visualized with a colposcope under high resolution with acetic acid staining and Lugol's iodine staining and the following findings were noted: RP LN lesion with glands, LL and LP AW lesions with CP, LN when Lugol's applied. There was a RL midcanal low-grade appearing area with faint punctations, RA there was a mixed Lugol's, anteriorly and LA were normal.*
Perianally, there were several whitish streaky plaques located posteriorly, RA, LA, almost stellate in appearance. The LA perianus had the largest PA lesion.
The 2 intraanal lesions were isolated and anesthetized with 0.5% Marcaine, and a hyfrecator set at 15 watts was used to cauterize the high grade lesions down to the vessels. Hemostasis was obtained with direct pressure. Biopsies x 1 was taken perianally after the LA perianal whitish plaque was anesthetized with 0.5% Marcaine with Baby Tischlers. Bleeding was scant and hemostasis was promoted with pressure to the biopsy site and Monsel's solution.
Well hope I helped you
Lady T
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