Gastroenterology Coding Alert

Gastros can perform ablation, cautery with same technique

You have to consider many factors when the gastroenterologist performs a colonoscopy with a polypectomy -- the type of scope, the surgical technique, and the polyp location.

But even if you pay attention to all of these factors and get them right on the claim, the insurance carrier will deny payment if you don't get the polyp removal method right. 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, says Sherri Brasher, insurance and billing specialist at Gastroen-terology Associates in Evansville, Ind.

If the physician performs polypectomy: Find out how she removed the polyp (either with biopsy or snare technique). In the case of multiple polyp removal, determine where on the colon each polyp was located and whether they were in separate locations or close enough to be considered one location. This is important because the number of polyp locations may affect the number of codes you can allowably report on your claim.

Next, you should check the method the physician used to remove each polyp, Brasher says.

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.

A partial polypectomy is usually a cold biopsy, Brasher says, whereas 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).

Although there is now a CPT code for a colonoscopy with directed submucosal injections (45381, Colonoscopy ...; with directed submucosal injection[s], any substance), you shouldn't automatically assume that every insurance carrier will accept it, Weinstein says.

CPT first included 45381 in its code book in 2003; the list of acceptable "substances" includes saline, India ink, methylene blue, Botox or steroids. Since it is still relatively new, the injection code 45381 may not be acceptable to all payers.

Time saver: Don't waste time filing a claim that's going to be denied. Because code 45381 is still new, some insurance carriers may not accept it. Be sure to verify coverage with your carrier before sending the claim, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.

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]) in the following situations: