# Using 45385 with 45381



## Feefer618

Hello all,
      Say a physician goes in and lifts a polyp using saline injection and then snares the polyp. I was taught that you are allowed one injection per polyp. If there is more than one injection, then you would bill the 45381. If there is tattooing, then you would bill the 45381. How is everyone else billing this? 
Thank you!


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## coachlang3

According to my 2011 Ingenix Coding Companion, pg 467:

"45381:The physician performs flexible colonoscopy of the proximal to splenic flexure.....Submucosal saline injections, for instance, may be done before polypectomy using snare and electrocautery to greatly enhance the effectiveness of resection for large sessile colorectal polypsd".

It then goes on to say in the next paragraph regarding coding tips:

"When submucosal injection is performed at the time of lesion removal, report seperately.  Report 45381 once regardless of the number of injections performed."

So the answer is you would bill 45385 and 45381 once no matter how many polyps removed or injected.


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## cedwards

*Did the guidance to bill 45381 and 45385 change?*

I have a physician who removed a polyp using the saline lift tequnique and snare so I billed Connecticare 45381 and 45385 and they denied the 45381 stating these cannot be billed together. I appealed it with a letter with all the documentation I had saying this was the correct way to bill this and they denied my appeal and say I have no more appeal rights.

AHHHH..

Thanks!


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## jojolynn

*45385 with 45381 Saline injection*

Have you reviewed the 45390 (2015 New CPT). I have a feeling that 45385, 45381 will no longer be accepted as this is more of an accurate code when snaring a polyp after a submucosal injection of saline. Any thoughts????


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## jojolynn

*45385 with 45381 Saline injection*

Have you reviewed the 45390 (2015 New CPT). I have a feeling that 45385, 45381 will no longer be accepted as this is more of an accurate code when snaring a polyp after a submucosal injection of saline. Any thoughts????


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## elaine.pulsepoint@icloud.com

*45390*

The new CPT 45390 is for EMR (endoscopic mucosal resection) and is more extensive than a saline injection and a snare.  You can refer to http://emedicine.medscape.com/article/1891659-overview  for details on the topic.

Certain commercial payers have their own medical policy and do not allow reporting of separate procedures and it's difficult to appeal them, especially within the short window of time they allow.  Aetna is difficult to appeal in a timely manner.

Make sure you've appended your modifier -59 to the additional code you're billing and also note that the payer may only allow 1 technique per unique polyp/location even with the -59.  

BCBS Clear Claims Connection online tool is a great source for checking coding scenarios against their code edit library.  Login to Webdenis and select "clear claims connection" on the main page and you'll be taken to an application where you can enter basic patient demographics (gender, age) and the CPT codes and modifiers you want to check against their edits.  Pretty slick, give it a try if you haven't.  It tells you if the scenario passes or fails their edits and why.

-Elaine


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## cdeville@ochsner.org

*Code 45390*



elaine.pulsepoint@icloud.com said:


> The new CPT 45390 is for EMR (endoscopic mucosal resection) and is more extensive than a saline injection and a snare.  You can refer to http://emedicine.medscape.com/article/1891659-overview  for details on the topic.
> 
> Certain commercial payers have their own medical policy and do not allow reporting of separate procedures and it's difficult to appeal them, especially within the short window of time they allow.  Aetna is difficult to appeal in a timely manner.
> 
> Make sure you've appended your modifier -59 to the additional code you're billing and also note that the payer may only allow 1 technique per unique polyp/location even with the -59.
> 
> BCBS Clear Claims Connection online tool is a great source for checking coding scenarios against their code edit library.  Login to Webdenis and select "clear claims connection" on the main page and you'll be taken to an application where you can enter basic patient demographics (gender, age) and the CPT codes and modifiers you want to check against their edits.  Pretty slick, give it a try if you haven't.  It tells you if the scenario passes or fails their edits and why.
> 
> -Elaine



I recently came back from a Gastroenterology Seminar in Little Rock.  First all you need to know the true meaning of an EMR - according to 2015 Gastroenterology Update by AGA - Endoscopic mucosal resection (EMR) can include injection-assisted, cap-assisted and ligation-assisted techniques.
All techniques involve 1) Identification and demarcation of the lesion; 2) Submucosal injection to lift the lesion; and
3) Endoscopic snare resection. Separate reporting of submucosal injection, banding or snare polypectomy is not
appropriate, as these services are bundled into the code for EMR. When biopsy is performed on the same lesion as
EMR, biopsy is not reported.  I was told if a submucosal injection is use to lift the lesion and then it is snared then 45390 is report for commerical insurance and 45378,G6021 is used to report to Medicare.  Its my understand 45385, and 45381 will not longer be excepted together by Medicare.  Anyone with information on denials or payments received on these codes would be very helpful.


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## Shaheedahp

*45385, 45381*

I am currently billing my procedures this way. I have been using 45390 in place of 45385, 45381-59. I bill for the hospital so I am not using the G-code, I was told this is only for the professional side.


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## dodo3000

We just started getting denials from BCBS on 45381 billed with 45385. The funny thing is that their Clear Claim Connection still says it's allowed when you bill 45385 with 45381. I was told by a rep that they all need to be appealed. 

Has there been any guidance regarding the different between EMR vs. saline-lift polypectomy? From what I've read it seems that EMR is more complex.

Angela Anderson, CPC


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## kmordway

How about a polyp that is snared and India ink is used?  The description for 45390 says fluid administered under the polyp to elevate it.  Snare and India ink is still 45385 and 45381.  59 modifier should not be used since it is not a CCI edit.  

Also, for ASC coders:  we are supposed to use the new 2015 codes for an ASC.  If Medicare is not recognizing the new codes and have a 0.00 RVU, if you have a professional claim with 45378 & G6021 and ASC claim with 45390, how is that going to process?!


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## drakena74

I'm an ASC Coder for GI in So. Cal.  I've coded and billed 45385 & 45381 together with no problems getting paid from our commercial carriers and Medicare.


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## rykin7609

*one step further*



kmordway said:


> How about a polyp that is snared and India ink is used?  The description for 45390 says fluid administered under the polyp to elevate it.  Snare and India ink is still 45385 and 45381.  59 modifier should not be used since it is not a CCI edit.
> 
> Also, for ASC coders:  we are supposed to use the new 2015 codes for an ASC.  If Medicare is not recognizing the new codes and have a 0.00 RVU, if you have a professional claim with 45378 & G6021 and ASC claim with 45390, how is that going to process?!



Okay, I need to take this one step further. 
I have a patient that had a polyp removed by the lift and cut technique with Snare and submucosal injection. 45930, easy. THEN the doctor injected the same area with Indian Ink for tattooing for future reference. This second injection is for a different procedure, would you or would you not add the 45381-59. CCI edits do not disallow it and yes, the parenthetical notes say that 45381 FOR LIFT INJECTION may not be used with 45390 , but the tattoo injection was not for a lift injection. 
Any thoughts?


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## afalcon@dhcla.com

I was told that if inject to lift and a snare is done to same polyp then to use the EMR code 45390.

If you snare the polyp and inject any ink, carbon, or spot you can use the 45385 for the snare and then 45381 for injection but add a note to the claim stating: 3ml of spot ink was injected to tattoo this site. Using the comment fields on the claim form has helped us now that ICD-10 codes the locations of the polyps.


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## rykin7609

right, however, the 49350 WAS done and then the doctor went back and injected with ink. What I am wondering is can we or can we not bill the 45381 with a 59 modifier FOR THE INK INJECTION, along with the 45390?

remember, the second injection is not for lifting for the resection, it is a marking of the area.

Please, let me know if anyone knows how to handle this. Thank you


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## afalcon@dhcla.com

then I would use 45390 then 45381 with claim notes saying it was tattooed with ink.


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## SUEV

afalcon@dhcla.com said:


> then I would use 45390 then 45381 with claim notes saying it was tattooed with ink.



Hi afalcon,
I have a question since you didn't mention the -59 modifier in the above quote  Are you saying you would add it to 45381 when tattooing the area around the lesion that was removed by 45390 or are you saying not to use the -59 and rely on a review of the notes included with the claim for payment of the bundled code?
Thanks,
Sue


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## afalcon@dhcla.com

SUEV said:


> Hi afalcon,
> I have a question since you didn't mention the -59 modifier in the above quote  Are you saying you would add it to 45381 when tattooing the area around the lesion that was removed by 45390 or are you saying not to use the -59 and rely on a review of the notes included with the claim for payment of the bundled code?
> Thanks,
> Sue



I wouldn't use a modifier at all. I would bill 45390 and 45381 with claim comments stating the amount of india ink, spot, or carbon that was injected for tattooing or later identification.


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## hrshea46

I am having this problem as well. This is happening to me on Blue Cross Medicare products. I have sent in appeals and was told to reference CMS processing manual chapter 12 Section 40.6. which says to add the 51 modifier to the lesser of the two services. I did this and still received a denial stating bundled service. 

I can not bill an EMR because this is a more comprehensive procedure requiring that a special cap device be used. 

If anyone can help I would greatly appreciate it.

Thank you in advance!


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