Use appropriate modifiers to unbundle codes, when necessary.
To assess a patient with rectal hemorrhage or pain, your gastroenterologist might opt for a proctosigmoidoscopy. Since this procedure is significantly similar to a more extensive sigmoidoscopy, you will have to know how to differentiate these two procedures for accurate coding or face denials to your claims.
1. Ascertain Insertion Approach
Since proctosigmoidoscopy involves examination of the most distal portions of the sigmoid colon and the rectum, your gastroenterologist has to perform this procedure by inserting the scope through the anus. This approach differs from upper endoscopy procedures where the scope is inserted through the mouth.
For example, if the documentation reads, “Scope inserted anally,” you can be rest assured that your gastroenterologist performed a lower gastrointestinal (GI) endoscopy and not an endoscopy of the upper GI tract.
2. Check Scope Type
The next step to differentiate between a proctosigmoidoscopy and a flexible sigmoidoscopy is to check the patient notes to see if there is a mention of the type of scope that your gastroenterologist used to perform the procedure. “Documentation should point to the specific type of scope used, rigid or flexible, as well as the parts of the colon examined,” says Heather Copen, RHIT, CCS-P, Certified Physician Coder – Goshen OB/GYN and Goshen GI, IU Health Goshen Physicians, Goshen, Indiana.
Since proctosigmoidoscopy involves only examining the distal portions of the sigmoid colon and rectum, your gastroenterologist can use a rigid scope in comparison to a flexible scope when performing a sigmoidoscopy. “If a rigid scope is used to view the rectum and sigmoid colon then CPT® codes 45300-45327 (Proctosigmoidoscopy, rigid…) should be assigned,” says Copen. “A rigid scope has limited viewing ability due to the inability to bend at the sigmoid flexure.”
Since sigmoidoscopy involves visualizing the...
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