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.

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 techniques represented in 45385 and 45384, the terminology used to indicate when 45383 is appropriate is not as clear-cut and knowing the definition of "ablation" doesn't help; it simply means "to remove or excise."

The definition of 45383 can be misleading because it only states what techniques the codes should not be used for: hot biopsy forceps (45384), bipolar cautery (45384) and snare (45385).

So what possible techniques are we left with? Code 45383 is reported when lesions, polyps, or angiodysplasias (fragile arteriovenous malformations) are destroyed using argon plasma coagulators (APC), lasers or heater probes, Weinstein says.

In many cases, these ablation procedures are performed during follow-up colonoscopies to remove, for example, the remainder of a large benign polyp partially removed by snare technique or hot forceps, he says. But don't assume that just because a polyp is destroyed in a follow-up colonoscopy that it was destroyed using APC, a laser or a heater probe. "There are several other devices that can be used to cauterize and 'ablate'small polyps or angiodysplasia vessels," Weinstein says. "One clue to selecting code 45383 is that the pathology samples are not generally obtained from lesions that are treated with an 'ablation'technique."

Be aware that APC, lasers and heater probes can also be used to control bleeding as well as for ablation. So even these terms can trigger the use of code 45383; you have to check the context to be sure the appropriate code isn't 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding ...). And remember, Weinstein says, "Physicians cannot charge for 'control of bleeding'that started as a result of the procedure or removal technique during the same procedure."