# Denials CPT 45385 with 45380



## lamiller (Jun 3, 2020)

I am having a lot of denials from Blue Cross Medicare Advantage in Tennessee when billing 45385 and 45380 together. I have tried several different modifiers on 45380 including, 59, XS. XU and 59/51. The denial comes back stating claim specific negotiated discount. Anybody have any ideas?


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## SharonCollachi (Jun 3, 2020)

45380: Colonoscopy, with biopsy, single or multiple

45385: Colonoscopy, with removal of tumor(s), polyp(s), or other lesion(s), by snare technique


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## lamiller (Jun 3, 2020)

SharonCollachi said:


> 45380: Colonoscopy, with biopsy, single or multiple
> 45385: Colonoscopy, with removal of tumor(s), polyp(s), or other lesion(s), by snare technique


I have the CPT codes correct for different techniques and different anatomical sites, they are not accepting any of the modifiers for 45380?


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## SharonCollachi (Jun 3, 2020)

In that link, you will find this:

_Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the  highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378). _

That looks like it might be saying they're not going to pay them separately.


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## lamiller (Jun 3, 2020)

SharonCollachi said:


> In that link, you will find this:
> 
> _Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the  highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378). _
> 
> That looks like it might be saying they're not going to pay them separately.


We were getting paid using modifier 59 on 45380 and then they stopped paying. I just can't seem to get a straight answer on our Representative about this. I don't want to write off the 45380 if they will pay somehow.


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## Rajinder_Dhammi (Jun 4, 2020)

Dear LaMiller,

You would never get paid for 45380 when billing with 45385, even after appending modifier 59.

*45380* is a procedure where colonoscopy is performed and a biopsy is taken (either single or multiple) whereas *45385 *is a procedure where colonoscopy is performed and tumor(s), polyp(s), or other lesions are removed (bigger than a biopsy, as biopsy is done only for diagnostic purposes, and here the lesion(s) is/are removed).

Consider yourself lucky to be paid before for 45380 WITH 59.  I will not be surprised if this insurance recoups whatever money is paid for 45380.  This CPT is clearly bundled with 45380.

I hope I am clear.

Thank you,
Rajinder Singh Dhammi, CPC, CPB


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## SharonCollachi (Jun 4, 2020)

I had originally answered up above about billing for more than one colonoscopy in one day or in one session.  Yet I kept finding advice about doing exactly that.  I'm still not grokking how a colonoscopy would be billed twice, instead of one colonoscopy plus a lesser procedure such as a lesion removal.  Then I edited my answer.

Even here on AAPC I found advice saying you can bill both.  Here.  Also, in that link the last poster said the NCCI edits say it's appropriate if separate lesions OR at separate encounters.

Oxford Health, for instance, has an "Endoscopy Adjustment Rule", which I quoted above.  So they would pay all of the first code, then not 50% of the second one, but take the second one and subtract the amount for a basic endoscopy.  Which pays it more like the way I thought it should in my first paragraph in this post.  I don't understand why there isn't an add-on code for work beyond the first procedure, because you're not going to the O.R. a second time, you're not doing an entirely new procedure start to finish.

I just found that the Oxford Health rule is a Medicare rule, it's in MLN Number MM7587.  It is effective 4/1/2012.


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## haraml7 (Jun 5, 2020)

lamiller said:


> I am having a lot of denials from Blue Cross Medicare Advantage in Tennessee when billing 45385 and 45380 together. I have tried several different modifiers on 45380 including, 59, XS. XU and 59/51. The denial comes back stating claim specific negotiated discount. Anybody have any ideas?



This is a Medicare Part C claim, and you would need to look into your contract with this payor. Sometimes with these payors there is a "negotiated rate" and a PRICE is Capped out at a certain amount for physicians. This would be a per provider/payor negotiation. This denial has nothing to do with the modifier. 

Your provider may have signed a capitation agreement with the insurance company, which would award the provider a fixed payment amount, Hence the reason for the "negotiated rate" denial. 

What is the denial code, and the remark codes?


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