# Billing for 2 Colonoscopy codes



## JoannaRupert (May 2, 2013)

I am trying to determine if a 45385 & 45380 can be billed together.  It's my understanding that we can bill both codes if the procedures were done on two seperate areas of the colon.  The op report states:

Findings:
- A sessile polyp was found in the sigmoid colon.  The polyp was 6 mm in size.  The polyp was removed with a hot snare.  Resection and retrieval were complete.

- A benign appearing sessile polyp was found in the rectum.  The polyp was 4 mm in size. The polyp was removed with a cold biopsy forceps.  Resection and retrieval were complete.

-A benign appearing sessile polyp was found in the rectum.  The polyp was 7 mm in size.  The polyp was removed with a hot snare.  Resection and retrieval were complete.

I billed both codes and added a 59 to the 45380 to show seperate and distinct procedures were performed.  The physician side paid on both codes but the facility side is denying.  I want to fight this if I am right .  Can anyone enlighten me?  Thanks.


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## pygreen (May 2, 2013)

You are correct in your code selection.  I would definitly appeal.   Also, you may want to check your payor contract for the facility charges.


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## JoannaRupert (May 2, 2013)

Thank you for the feedback.  I wonder if it is because I have to bill these charges on a UB04 and there are no diagnosis pointers like a HCFA 1500 so they are not really understanding what code goes to what area of the colon.  Would I be better off dropping these charges on two seperate UB04's?


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## bdobyns (May 2, 2013)

you might want to verify that your contract includes multiple procedure processing and its not subject to a case rate or per diem rate.  If your contract does allow for multiple procedure processing then you could try an appeal using this information as a well other resources like the NCCI edits.  Billing the two on separate claims could create confusion for the payor and likely result in a duplicate denial.


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## bridgettemartin (May 3, 2013)

I agree with your code selection and the others suggesting you check your contract with the payer.  It could be that your contract doesn't allow payments for multiple procedures on the facility side.  I would not separate them.


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## coachlang3 (May 3, 2013)

I have to disagree with everyone saying the coding is correct.  In my opinion she shouldn't have coded the 45380 for the rectal polyp as there was also a snare of a rectal polyp.  And she already had a snare on the charge.

You need to code to the highest level of specificity and that would be the rectal polyp with snare.

Maybe some didn't see the rectal polyp snare?

Could she have added a 22 modifier?  Maybe.


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## bridgettemartin (May 3, 2013)

coachlang3 said:


> I have to disagree with everyone saying the coding is correct.  In my opinion she shouldn't have coded the 45380 for the rectal polyp as there was also a snare of a rectal polyp.  And she already had a snare on the charge.
> 
> You need to code to the highest level of specificity and that would be the rectal polyp with snare.
> 
> ...




I disagree, Coach. Even though a rectal polyp was removed by snare, a separate rectal polyp was removed by biopsy.  To me it would be no different if two polyps were found in the ascending colon and one was removed by snare, and the other by forceps, I would bill both techniques since they are different polyps. I haven't read anything that would lead me to believe this wouldn't be correct. If the provider tried to remove the polyp with forceps, and then fully removed it with snare, then yes, I would only bill the snare.


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## coachlang3 (May 3, 2013)

Actually, CCI edits show to not use 45385 and 45380 together unless you can show they were done in separate anatomical regions.

If the doctor had not also removed a rectal polyp via snare technique then yes, it would have been appropriate to bill the 45385 with a 211.3 and a 45380, 59, 569.0 because it would have been different techniques in different anatomical areas but there was also a snare in the rectum which makes it a moot point.

You must always code to the highest level of specificity if possible.  45385 is for snare of a polyp(s) or lesion(s).  Does not matter how many specimens or how many anatomical sites you snare.  The highest level of specificity in the rectum is 45385 therefore the 45380 is inappropriate in this instance.

I do agree with everyone about the facility issue though.  Many payors don't cover a facility's second procedure if it is at all related to the first.  They will pay for one colon and one EGD at the same time and that's it.  They won't pay for multiple colon's (such as this case).  A lot will but a lot won't also.


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## bridgettemartin (May 3, 2013)

coachlang3 said:


> Actually, CCI edits show to not use 45385 and 45380 together unless you can show they were done in separate anatomical regions.
> 
> If the doctor had not also removed a rectal polyp via snare technique then yes, it would have been appropriate to bill the 45385 with a 211.3 and a 45380, 59, 569.0 because it would have been different techniques in different anatomical areas but there was also a snare in the rectum which makes it a moot point.
> 
> ...



Interesting point which I am going to research further.  Based upon your statement above, do you also feel that if two polyps were in the transverse colon and one was removed with snare and one with biopsy that you would only bill for the snare?  Even if they are at opposite ends of the transverse?  Or what if the provider only states distance?  Like one removed by snare at 80 cm, and another removed by forceps at 83 cm?


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## mitchellde (May 3, 2013)

first you cannot use the 211.3 dx code as there is not path report, the provider only stated they were benign appearing , which is a statement that is not codeable.
I agree that you can bill only one snare code, but when a different technique is employed for a distinctly different polyp then you can charge for that.  
The facility should be able to bill for both procedures, however remember the facility CCI edits are slightly different from the physician, so you would need to check those to see if the are a mutually exclusive edit.


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## coachlang3 (May 3, 2013)

That's exactly what I am saying.  You must code the most appropriate code for each anatomical site examined.

You may only bill/charge/code for the most comprehensive code done in each anatomical site.  And then to top it off if the doctor snares a polyp in each site and does a hot biopsy in the transverse and a cold biopsy in the sigmoid he can still only code/bill/charge for the snare, and only once.

You bring up a good point about the distance also.  I think there was an article in the AAPC coding mag about knowing the different areas by distance (which I don't off the top of my head).  If the doctor lists by distance instead of anatomical site you'll want to know because 80cm and 83cm could be different anatomical sites of the colon (not sure if they are, just saying it as an example).


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## coachlang3 (May 3, 2013)

mitchellde said:


> first you cannot use the 211.3 dx code as there is not path report, the provider only stated they were benign appearing , which is a statement that is not codeable.



True.  It should probably be 235.2


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## coachlang3 (May 3, 2013)

OK, here's what I found regarding this in the CCI edits policy for section VI:

"20. A biopsy performed at the time of another more extensive procedure (e.g., excision, destruction, removal) is separately reportable under specific circumstances.
If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59.
If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability. When separately reportable modifier 58 may be reported to indicate that the biopsy and the more extensive procedure were planned or staged procedures.
If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure.

22. The NCCI edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT code 45380 of this NCCI edit is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.

23. If the code descriptor of a HCPCS/CPT code includes the phrase, “separate procedure”, the procedure is subject to NCCI edits based on this designation. CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach."

From reading that I feel it's still murky.

I also have booklet from Kathleen Mueller, who is one of the AGA's coding and billing specialists, and on page 94 it states "More than one surgical endoscopy can be performed and can be reported as long as it was a different technique and different site in the intestine."  This is from her Coding, Billing & Compliance Update for Gastroenterology that she puts out yearly.

So go about it as you see fit.  I can't find concrete evidence either way.  But I do stress what Deb was saying about not using 211.3.  Don't, unless you already have the pathology report saying it is benign.  For anal/rectal polyps 569.0 is appropriate and in place of 211.3, 235.2 or 235.5 are appropriate.


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## mitchellde (May 3, 2013)

I do feel it is very clear that you can bill both the snare and the cold forceps removal as they are documented in distinctly different areas which is what the CCI rules state.  However you cannot use 211 codes nor can you use 235 codes, both of these diagnosis must have a path report before coding, a polyp has not yet been examined histologically and benign and uncertain behavior are both diagnosis render after a histologic examination.  You can code it as a polyp.  which is I believe a 569 code but you should look it up.


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## Colliemom (May 21, 2013)

Question:

You are billing 45385 for a Hot snare and 45380 for cold bx.

I have a doctor who is trying to bill 45384 for a hot snare, but I believe this is incorrect, as I believed 45384 was only for Hot biopsy forceps, not for hot snare. 

does anyone use 45384 for a hot snare?


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## chewri (May 21, 2013)

*multiple procedures*

I work in endoscopy ASC and always bill for all forms of removal of bx using the 59 modifier as long as it is in different areas on the intestines. I have never had a issue with this unless for some reason the claims go out of different claim forms. Again I refer you to the cutting edge Oct 12 issue that clearly states how to bill these multiple procedures.


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