How Do You Code Sigmoidoscopy with Anoscopy, Biopsy?

October 13, 2009

Question: Notes indicate that the gastroenterologist performs a rigid sigmoidoscopy; during the encounter, he also performs an anoscopy without anesthesia and three biopsies of the mucous membrane. How should I report this episode? Can I report the exam separately with 46600?

Answer: You can report a single code for these three services. On the claim, report 45305 (Proctosigmodoscopy, rigid; with biopsy, single or multiple) for the sigmoidoscopy, the anorectal exam, and the three biopsies.

Why: When the gastroenterologist performs an anoscopy (46600 [Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or mucous membrane biopsy during a sigmoidoscopy, the services are bundled into 45305.

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