Gastroenterology Coding Alert

Unless your gastroenterologist has a perfect record of clearly documenting the technique used to remove tumors, you need to know all possible terminology for describing codes 45385, 45384 and 45383, or you could be mistaking a snare technique for hot forceps. Coders are often confused by codes 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), 45384 ( with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) and 45385 ( with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) because they are differentiated only by the method used to remove a lesion, and the gastroen-terologist doesn't always clarify in his documentation exactly which method he used. You have to know what differentiates each code to be able to determine whether multiple techniques were used to remove multiple lesions you can be reimbursed for more than one lesion removal code with modifier -59 (Distinct procedural service), says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. Use these descriptions of the different techniques represented in the lesion removal codes when trying to identify the technique described by your gastroenterologist in the operative report. Master the Most Common Technique First The lesion removal technique easiest to identify is the snare technique, represented by code 45385. Snare technique is most often used to perform a polypectomy during a colonoscopy.

When the snare technique is employed, a wire loop (the electrocautery snare) is heated and then used to shave off a lesion or polyp. "Snare devices may also be used without electrocautery to 'decapitate'small polyps," Weinstein says. Most often the gastroen-terologist will specify that a snare technique was used, but don't let alternative terminology throw you off. A gastroenterologist may also use "hot snare," "monopolar snare" or "bipolar snare," all of which should be coded with 45385. You can't assume that you will need to report code 45385 for a snare technique every time you see the terms "monopolar" and "bipolar" used to describe how a lesion was removed.

When a gastroenterologist documents using bipolar cautery or a monopolar current to remove a lesion, you may be looking for code 45384 to accurately report his services. Bipolar cautery uses current that runs from one portion of the tip of the cautery device to another to remove a lesion or polyp. And hot biopsy forceps use a monopolar current and a grounding pad on the patient's body to snip off and cauterize a polyp or lesion at the same time.

Unfortunately, unlike the terminology gastroenterol-ogists may use to describe the [...]