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Query the provider before choosing an unspecified code.

It鈥檚 essential to thoroughly examine the medical records when your surgeon performs colorectal procedures. Details such as the technique applied and the presence of polyps or related removal methods should be noted, and any extra work should be accounted for.

How prepared are you to code these procedures? Take this quiz and assess your understanding of colorectal coding.

Anatomy review: The journey of the colon begins with the cecum, located in the lower right abdomen, with the appendix attached to it. Going upward, the colon enters the ascending colon, which runs vertically on the right side of the abdomen. The colon then takes a bend, transitioning into the transverse colon, which stretches horizontally across the abdomen. Another bend occurs and the colon turns downward, forming the descending colon on the left side of the abdomen. Finally, the colon curves inward, becoming the sigmoid colon, which connects to the rectum.

Question 1: Are you allowed to report a separate evaluation and management (E/M) code for the surgeon鈥檚 prescreening colonoscopy visit with the patient?

Answer: Unfortunately, no. Not unless the surgeon documents a separate chief complaint related to that visit.

Part B Medicare Administrative Contractor (MAC) recognizes that some surgeons like to perform an E/M before colonoscopies but reminds coders that, 鈥渢he physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable.鈥�

Question 2: Which ICD-10-CM code would you choose for the following polyp removal surgery that your general surgeon recently conducted? The patient record describes the mass as a 鈥減olyp located high in the colon.鈥�

As you have probably noticed, there are seven polyp codes for the colon region to choose from:

• D12.0 (Benign neoplasm of cecum)
• D12.1 (鈥� appendix)
• D12.2 (鈥� ascending colon)
• D12.3 (鈥� transverse colon)
• D12.4 (鈥� descending colon)
• D12.5 (鈥� sigmoid colon)
• D12.6 (Benign neoplasm of colon, unspecified)

Answer: When it comes to coding for polyp removal, having detailed and accurate information regarding the polyp鈥檚 location is crucial for accuracy. In this situation, you鈥檒l need to query the provider for more detailed information.

Keep in mind, D12.6 may seem like an easy option, but this code should only be used if the provider does not have more detailed information. The provider in the above scenario has the location but didn鈥檛 use the technical term for the exact location. The ICD-10-CM codes are location-specific, so given that this information is likely just a query away, D12.6 may be incorrect.

Question 3: During a screening colonoscopy, the surgeon documented finding hemorrhoids, but did not document anything about treating the condition. Are you able to code this as a diagnostic colonoscopy because of the abnormal finding?

Answer: No, you should not code this as a diagnostic colonoscopy in this case. This is, of course, assuming there is documented evidence of the ordering physician鈥檚 request for a medically necessary screening colonoscopy.

Because the hemorrhoids were considered an incidental finding during the screening procedure and not something that created a cancer scare, the surgeon should document these findings for the sake of the medical record and future care. But these findings wouldn鈥檛 change the reason for the procedure, so there鈥檚 no need to change the procedure code. In addition to hemorrhoids, incidental colonoscopy findings might include diverticulosis or anal fissures. You should report any of these as a secondary diagnosis following the ordering diagnosis of Z12.11 (Encounter for screening for malignant neoplasm of colon) as the primary code.

What鈥檚 the difference? If you鈥檙e like many coders, you may have trouble determining a screening from a diagnostic test. According to the , 鈥淎 screening test is a test provided to a patient in the absence of signs or symptoms 鈥� for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.鈥� A diagnostic colonoscopy, however, is performed 鈥渁s a result of an abnormal finding, sign or symptom.鈥�

Question 4: The surgeon performed a 鈥渉ot biopsy鈥� for a polypectomy, according to their note. How should you code this?

Answer: The code you choose will depend on the type of scope procedure the surgeon performed when removing the polyp. You might choose from one of the following codes, among others:

• 43216 (Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 43250 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 44365 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery)
• 45333 (Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 45308 (Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery).

The hot biopsy technique involves the use of insulated monopolar electrocoagulating forceps to simultaneously biopsy and electrocoagulate tissue. Normally, the procedure is used for the removal of diminutive polyps and to treat vascular ectasias of the gastrointestinal tract. This technique not only accomplishes the ablation of the neoplastic tissue but also provides the sample for the pathologist to use for diagnostics.

Due to the risk of delayed perforation or bleeding, hot biopsy forceps are used much less frequently now than in the past. However, they are still occasionally used.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC