Lower Gastrointestinal Endoscopies

Lower GI procedures involve the small bowel, colon, and rectum. Indications for
lower GI
procedures include evaluation of an abnormal barium enema, lower gastrointestinal
bleeding,
iron deficiency anemia of unknown etiology, diarrhea, or follow-up examination
after removal
of a neoplastic growth.

When coding lower gastrointestinal endoscopies, coders must distinguish among the
following:

� Proctosigmoidoscopy, which is an examination of the rectum and sigmoid colon

� Sigmoidoscopy, which is an examination of the entire rectum, sigmoid colon, and

may
include part of the descending colon

� Colonoscopy, which is an examination of th ntire colon, from rectum to cecum,

with
possible examination of the terminal ileum

For a colonoscopy, the first step in cho ing a code is to determine the route the
procedure is
to follow:

� Via stoma (44388-44408)

� Via rectum (45378-45398)

If a patient was scheduled and fully prepped for a colonoscopy, but the procedure
was incom�
plete because the physician was unable to advance the colonoscope beyond the
splenic flexure
due to unforeseen circumstances, the colonoscopy code with modifier -53 would be
reported,
along with appropriate documentation.

Colonoscopies should be coded based on how far the scope was passed, not on the
level
where a biopsy was performed or a polyp was removed.

The following general guidelines apply to the coding of colonoscopies:

� When, during a colonoscopy, a polyp is removed and another area of the colon is
biop�
sied, it is proper to code both procedures.

� When a biopsy of a lesion is taken and the lesion also is excised, only the
excision
should be coded.

� It is possible for a physician to use different technique to remove separate

polyps dur�
ing the same operative episode. In this case, the appropriate CPT code is assigned
to
identify each technique.
If more than one procedure is performed via the endoscopy, a code must be assigned
for each
component.

The CPT code bo k re gniz s the use of everal techniques in performing

polypectomies
through a colonoscope:

� Hot biopsy forceps technique (45384), which utilizes hot biopsy forceps
resembling
tweezers connected to an electrosurgical unit. Grasping the polyp with the hot
biopsy
forceps, the physician pulls the growth away from the wall of the colon. This
technique
prevents bleeding, as seen with a cold biopsy, and is generally used on small
polyps of
5 mm or less. A portion of the neoplasm may be removed for pathological analysis.
The
remaining portion is destroyed with the electrocoagulation current.