tci General Surgery Coding Alert - 2014 Issue 4

You Be the Coder: Scope Advancement Leads Code Selection

Question: During a colonoscopy, the surgeon noted “a fungating circumferential bleeding mass of malignant appearance in the proximal rectum and distal sigmoid colon at 15 cm from the anus. The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Cold forceps biopsies were performed. Four 1 ml india ink injections were successfully applied for tattooing.” Should I bill this as a colonoscopy with biopsy and tattoo, or a flexible sigmoidoscopy with biopsy and injection? Kentucky Subscriber Answer: You should not bill a colonoscopy unless the surgeon passed...

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