Question: May I report more than one removal code if the physician employs more than one method to remove multiple colon polyps?Pennsylvania Subscriber
Answer: You should report all polyp-removal codes once per operative session, regardless of the number of polyps the physician removes. Therefore, when he performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you cannot report multiple codes.
- For instance, if the doctor removes and cauterizes three polyps during a colonoscopy, you should report a single unit of 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery: APC 0143) to describe the encounter.
- In contrast, if the physician ablated one polyp with an argon plasma coagulator, then removed the other two by snare technique, you would report the following:
• 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique: APC 0143) for the argon plasma coagulator ablation
• 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique: APC 0143) for the polyp removals with the snare.-
You should append modifier 59 (Distinct procedural service) to 45385 to show that the ablation and the snare removals were two distinct procedures.
Important: Documentation must provide medical justification for the physician’s decision to use two different removal methods.
-- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
