Gastroenterology Coding Alert

Deciphering the type of scope, surgical technique, and polyp location from your gastroenterologist's colonoscopy-with-polypectomy claim is only half the battle. You have to get the polyp removal method right and apply the appropriate code.

Read on for more information about different types of polyp removal and how to spot each type of removal method on an operative report.

First, you must read the gastroenterologist's dictation and verify that he performed a colonoscopy. You should also look for how he removed the polyp (either with biopsy or snare technique).

Important: "Different CPT codes for polypectomies mean you need to know which technique your physician used to bill the service correctly," says Dena Rumisek, biller for Grand River Gastroenterology PC in Grand Rapids, Mich.

While you're studying the op report, check out where the polyp(s) is/are located.

Multiple polyps: In the case of multiple polyp removal, you need to know:

• where on the colon each polyp was located and

• whether they were in separate locations or close enough for payers to consider one location.

Why: This is important because the number of polyp locations may affect the number of codes you can allowably report on your claim, says Heather Lammert, senior billing coordinator of Gastroenterology Associates of PGH in Pennsylvania.

A partial polypectomy usually means you're looking at a cold biopsy forceps.

What are cold forceps? Cold biopsy forceps are disposable forceps that the physician uses to take tissue samples during an endoscopy. No electric current passes through them -- thus, the term "cold." You cannot use these forceps to cauterize bleeding that the forceps may cause.

When the gastroenterologist takes tissue samples with cold biopsy forceps, you should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). Also, if the gastroenterologist completely removes a small polyp using cold biopsy forceps, you should report 45380 as well, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel.

On the other hand, a total polypectomy may mean snare technique.

What does "snare" mean? Physicians typically perform a total or entire procedure with an electrocautery snare (a heated wire loop that shaves off the polyp).

When the gastroenterologist uses snare technique during a total polypectomy, you should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Keep in mind: If many polyps exist in various regions -- and the physician spends a lot of time removing the polyps -- you should report 45385 and attach modifier 22 (Increased procedural services) so the physician is compensated and reimbursed for his time. There is no standard, but double the usual amount of time is reasonable for use of modifier 22. For instance, if the gastroenterologist spends 10 extra minutes on a procedure that normally takes 40 minutes, you wouldn't use modifier 22.

To increase your modifier 22 claim's chances of success with the carrier, remember to record:

• the exact amount of time the procedure normally takes

• about how much longer the procedure took in this scenario.

Suppose your physician removes a polyp using the snare technique, but during the same session (while investigating the transverse colon), he sees a suspicious area that he injects with India ink.

In this situation, you should report 45385 for the polypectomy, and you may also submit 45381 (... with directed submucosal injection[s], any substance) to represent the injection.

Remember: The Correct Coding Initiative (CCI) does not bundle 45381 to 45385, and therefore you shouldn't need to add modifier 59 (Distinct procedural service) to 45381. The polyp removal and India-ink injection are separate procedures. If your payer rejects the claim, be sure to point to the CCI as evidence that these procedures are not bundled.

No, it's not a trick: Gastroenterologists may use many of the same techniques for cauterization (to control bleeding) and for ablation -- and the code definition can also be confusing. But the defining factor is the clinical situation and diagnosis, Weinstein says.

For example, use 45382 (Colonoscopy ...; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) when the gastroenterologist:

• controls bleeding from a polypectomy site several days after the initial polyp removal

• is treating diverticulosis with hemorrhage (562.12, Diverticulosis of colon with hemorrhage)

• is treating diverticulitis with hemorrhage (562.13, Diverticulitis of colon with hemorrhage)

• is treating angiodysplasia with hemorrhage (569.85, Angiodysplasia of intestine with hemorrhage).

Note: You cannot separately bill 45382 if the gastroenterologist has caused the bleeding during the colonoscopy. If, for example, the gastro causes bleeding during a diagnostic colonoscopy and has to cauterize, you should report only 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). Rationale: Even though the gastroenterologist had to use cautery to control bleeding, the colonoscopy code's (45378) surgical package includes physician-caused bleeding.

Overlooking what to do when your physician performs an ablation during a follow-up colonoscopy could lead to lost revenue.

What is ablation? Ablation usually refers to a cauterization technique the physician performs with an argon plasma coagulator, heater probe, or other device that destroys any remaining polyp cells after a prior colonoscopy in which the surgeon removed a larger polyp using a snare.

When your gastroenterologist uses any of these methods for an ablation of a non-bleeding angiodysplasia or polyp tissue from a site where tissue was not removed during the same procedure, you should report 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Watch out: Don't report 45383 when the gastroenterologist uses any of the following methods to ablate the remainder of a polyp immediately after removal of most of the polyp by another method, Weinstein says:

1. If the gastro removes and then ablates with hot biopsy forceps, report 45380 instead.

2. When the physician uses bipolar cautery for removal followed by ablation, opt for 45384 on your claim.

3. You should code snare-technique removal followed by ablations with 45385.

Hot forceps bipolar cautery: When the gastroenterologist both removes and cauterizes a polyp simultaneously using hot biopsy forceps, you should use 45384 (Colonoscopy ...; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). You can also apply this code when the physician uses either a monopolar hot biopsy forceps or a bipolar cautery forceps, Weinstein says.