Lower GI Endoscopy Coding for 2015

CPT 2015 brings major changes to lower GI endoscopy coding. This quick reference guide provides an overview of the changes and offers a crosswalk from old to new codes, as well as important guideline and reporting changes.

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Colonoscopy

The definition of a complete colonoscopy has been revised. Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis.

Instructions on appropriate use of modifiers 52 and 53 have been revised. When performing a colonoscopy on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 with modifier 53 with appropriate documentation. For therapeutic exams that do not reach the cecum, report the appropriate colonoscopy code with modifier 52 with appropriate documentation.

Endoscopy

New language in the guidelines clarifies that control of bleeding that occurs as a result of an endoscopic procedure is not separately reportable during the same operative session.

Ileoscopy

New instructions direct users to report ileoscopy through stoma for endoscopic examination of a patient who has an ileostomy. 

Pouchoscopy

New instructions direct users to report pouch endoscopy codes for endoscopic examination of a patient who has undergone resection of colon with ileo-anal anastomosis (e.g., J pouch).

Flexible Sigmoidoscopy

Guidance has been added to report flexible sigmoidoscopy for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure. Flexible sigmoidoscopy should be reported for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (e.g., subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. 

Colonoscopy Through Stoma

Colonoscopy through stoma is now defined as the examination of the colon, from the colostomy stoma to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. When performing a colonoscopy through stoma on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the colon-small intestine anastomosis due to unforeseen circumstances, report 44388 with modifier 53 with appropriate documentation. For therapeutic exams that do not reach the colon-small intestine anastomosis, report the appropriate colonoscopy through stoma code with modifier 52 with appropriate documentation.

CPT 2014

CPT 2015
Crosswalk

Short
Description

Changes
Overview

ILEOSCOPY
44380 44380 Ileoscopy
Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).” 
44382 44382 Biopsy No change.
NEW 44381 Balloon dilation
Report new code 44381 with modifier 59 for each additional stricture dilated. Not separately reportable with stent placement code 44384 for the same lesion. Use 74360 if fluoroscopic guidance is performed. 
44383 44384 Stent placement
Code 44383 has been deleted. New code 44384 includes pre- and post-dilation and guide wire 
passage. Not separately reportable with dilation code 44381. Use 74360 if fluoroscopic guidance 
is performed.
POUCHOSCOPY
44385 44385 Pouchoscopy
Editorial: Terminology updated to include Kock pouch and ileal reservoir [S or J] as examples. “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”
44386 44386 Biopsy No change.
COLONOSCOPY THROUGH STOMA
    Changes in colonoscopy guidelines section
New definition: Colonoscopy through stoma is now defined as the examination of the colon, from the colostomy stoma to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. When performing an endoscopic procedure on a patient who 
is scheduled and prepared for a colonoscopy through stoma, if the physician is unable to advance the 
colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 44388 with modifier 53 with appropriate documentation. For therapeutic exams that do not reach the colon-small intestine anastomosis, report the appropriate colonoscopy through stoma code with modifier 52 with appropriate documentation.
44388 44388 Colonoscopy through stoma
Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces 
“with or without collection of specimen(s).” 
44389 44389 Biopsy No change
44390 44390 Foreign body removal “Foreign body(s)” replaces “foreign body.” Use 76000 if flouroscopic guidance is performed.
44391 44391 Control of bleeding
“Any method” replaces previous examples. Not separately reportable with injection described by 44404 for same lesion.
44392 44392 Hot biopsy Bipolar cautery was deleted as an example.
44393 44401 Ablation
Code 44393 has been deleted. New code 44401 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 44405 for the same lesion.
44394 44394 Snare Not separately reportable with endoscopic mucosal resection described by 44403 for the same lesion.
44397 44402 Stent placement
Code 44397 has been deleted. New code 44402 includes pre and post dilation and guide wire passage. Not separately reportable with dilation code 44405. Use 74360 if fluoroscopic guidance is 
performed. 
NEW 44403 Endoscopic mucosal resection (EMR)
New code 44403 is not separately reportable with biopsy, submucosal injection or snare described by 
44389, 44394, 44404 for the same lesion.
NEW 44404 Submucosal resection
New code 44404 is not separately reportable with endoscopic mucosal resection or control of bleeding described by 44391, 44403 for the same lesion.
NEW 44405 Balloon dilation
New code 44405 for transendoscopic balloon dilation. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 44401, 44402. Use 74360 if fluoroscopic guidance is performed.
NEW 44406 Endoscopic ultrasound
New code 44406 is not separately reportable with EUS FNA code 44407 or radiologic ultrasound code 76975. Report only once per session.
NEW 44407 Endoscopic ultrasound (EUS) with FNA
New code 44407 is not separately reportable with EUS code 44406 or radiologic ultrasound codes 76942, 76975. Report only once per session.
NEW 44408 Decompression
New code 44408 for decompression for pathologic distention, such as volvulus or megacolon. Includes placement of decompression tube when performed. Report only once per session.
44799 44799 Unlisted procedure, small intestine Specifies unlisted procedure of the small intestine.
FLEXIBLE SIGMOIDOSCOPY
45330 45330 Flexible sigmoidoscopy
Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).” 
45331 45331 Biopsy Not reportable with 45349 for the same lesion.
45332 45332 Foreign body removal “Foreign body(s)” replaces “foreign body.” Use 76000 if fluoroscopic guidance is performed.
45333 45333 Hot biopsy Bipolar cautery was deleted as an example.
45334 45334 Control of bleeding
“Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion.
45335 45335 Submucosal injection
Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45334, 45349 for the same lesion. 
45337 45337 Decompression
New language clarifies decompression for pathologic distention, such as volvulus or megacolon. Includes placement of decompression tube when performed. Report only once per session.
45338 45338 Snare Not separately reportable with endoscopic mucosal resection described by 45349 for the same lesion.
45339 45346 Ablation
Code 45339 has been deleted. New code 45346 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45340 for the same lesion.
45340 45340 Dilation
New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45346, 45347. Use 74360 if fluoroscopic guidance is performed.
45341 45341 Endoscopic ultrasound
Report only once per session. Not separately reportable with EUS FNA code 45342 or radiologic 
ultrasound codes 76872, 76975.
45342 45342 Endoscopic ultrasound (EUS) wtih FNA
Report only once per session. Not separately reportable with EUS code 45341 or radiologic ultrasound codes 76872, 76942, 76975.
45345 45347 Stent placement
Code 45345 has been deleted. New code 45347 includes pre- and post-dilation and guide wire passage. Not separately reportable with dilation code 45340. Use 74360 if fluoroscopic guidance 
is performed. 
NEW 45349 Endoscopic mucusal resection
New code 45349 is not separately reportable with biopsy, submucosal injection, snare or band ligation described by 45331, 45335, 45338, 45350 for the same lesion.
NEW 45350 Band ligation
New code 45350 is not separately reportable with control of bleeding code 45334 for the same lesion. Do not report in conjunction with EMR or hemorrhoidectomy described by 45349, 46221. Report control of active bleeding with band ligation with 45334.
COLONOSCOPY
    Changes in colonoscopy
New definition: Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. 
45355 45399 Transabdominal colonoscopy via colotomy Code 45355 has been deleted. Report with new code for unlisted colon procedure, 45399.
45378 45378 Colonscopy
Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis.
45379 45379 Foreign body “Foreign body(s)” replaces “foreign body.” Use 76000 if fluoroscopic guidance is performed.
45380 45380 Biopsy Not separately reportable with EMR code 45390 for the same lesion.
45381 45381 Submucosal injection
Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45382, 45390.
45382 45382 Control of bleeding
“Any method” replaces previous examples. Not separately reportable with injection or banding of 
hemorrhoids described by 45381, 45398 for same lesion.
45383 45388 Ablation
Code 45383 has been deleted. New code 45388 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45386 for the same lesion.
45384 45384 Hot biopsy Bipolar cautery was deleted as an example.
45385 45385 Snare Not separately reportable with endoscopic mucosal resection described by 45390 for the same lesion.
45386 45386 Dilation
New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45388, 45389. Use 74360 if fluoroscopic guidance is performed.
45387 45389 Stent placement
Code 45387 has been deleted. New code 45389 includes pre and post dilation and guide wire passage. Not separately reportable with dilation code 45386. Use 74360 if fluoroscopic guidance is performed. 
45391 45391 Endoscopic ultrasound
Now specifies exam limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. Report only once per session. Not separately reportable with EUS FNA code 45392 or radiologic ultrasound codes 76872, 76975.
45392 45392 Endoscopic ultrasound (EUS) with FNA
Now specifies exam limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. Report only once per session. Not separately reportable with EUS code 45391 or radiologic ultrasound codes 76872, 76942, 76975. 
NEW 45390 Endoscopic mucosal resection (EMR)
New code 45390 is not separately reportable with biopsy, submucosal injection, snare or band ligation described by 45380, 45381, 45385, 45398 for the same lesion.
NEW 45393 Decompression
New code 45393 for decompression for pathologic distention, such as volvulus or megacolon. Includes placement of decompression tube placement when performed. Report only once per session.
NEW 45398 Band ligation
New code 45398 is not separately reportable with control of bleeding code 45382 for the same lesion. Do not report in conjunction with EMR or hemorrhoidectomy described by 45390, 46221. Report control of active bleeding with band ligation (s) with 45382. 
NEW 45399 Unlisted procedure, colon New code 45399 has been added for unlisted procedures of the colon.