Gastroenterology Coding Alert

If you don't correctly code your gastroenterologist's polyp-removals methods, you could be risking denials on your claims. But how do you choose between the codes? Look to the polyp removal technique for the answer. Here's how.

Gastroenterologists usually perform a total or entire polypectomy with an electrocautery snare -- a heated wire loop that shaves off the polyp. When the physician uses the 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).

Ablation usually refers to the cauterization of a polyp during a colonoscopy when the polyp cannot be removed by other techniques or during follow-up colonoscopy when your gastroenterologist discovers remnants of previously removed polyps. The physician uses an argon plasma coagulator, heater probe, or other device to destroy any remaining polyp cells after an earlier colonoscopy in which the physician removed a larger polyp using a snare.

When your gastroenterologist uses any of these methods for an ablation of either a non-bleeding angiodysplasia or polyp tissue from a site where tissue was not removed during the same procedure, you should report 45383 (... not amenable to removal by hot biopsy forceps,bipolar cautery or snare technique).

If your gastroenterologist uses bipolar forceps to both remove and cauterize a polyp simultaneously, you should report 45384 (... with removal by hot biopsy forceps or bipolar cautery). You can also apply this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

If your gastroenterologist uses the same technique to remove both polyps, you would report it with one code. For instance, you would report 45384 if your doctor used hot biopsy forceps to perform polyp removals at different sites at the same time.

Rule of thumb: No matter how many tumors, polyps, or lesions the doctor treats by the similar techniques, remember that the words "tumor(s), polyp(s), or other lesion(s)" in the descriptions of 45383, 45384, and 45385 signal that you're also restricted to reporting only one of these codes per colonoscopy.

Example: A patient came in to the ambulatory surgical center (ASC) for a screening colonoscopy. The gastroenterologist found two polyps in the sigmoid colon and another two polyps in the ascending colon. She removed them all with hot forceps. Even though your gastroenterologist removed four polyps, she used the same technique for all four. Therefore, you can only report 45384 once, not four times.

Exception: When the surgeon uses different techniques, however, you can bill multiple tumor, polyp, or lesion removals, as long as you report each code only once per technique.

Two polyps, two techniques: Your gastroenterologist used the snare technique to remove the first polyp and hot biopsy forceps to remove and control bleeding during the second polyp removal. As long as documentation supports the need for using different techniques on different polyps, you should report both 45385 and 45384.