Gastroenterology Coding Alert

Experts say the defining factor for control of bleeding is clinical situation and diagnosisDeciphering 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.Step 1: Verify Colonoscopy, Polypectomy TechniqueFirst, 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. Step 2: Determine Removal MethodA 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. [...]