Gastroenterology Coding Alert

The factors you have to consider when coding colonoscopies can seem endless types of procedures, various surgical techniques, instruments and locations, and, of course, avoiding bundling but remembering a few helpful hints will turn this coding maze into a breezeway.

1. Answer Three Questions: What? Where? How?
 
 First, read the physician's dictation and verify that a colonoscopy was performed, says Sherri Brasher, insurance and billing specialist at a physician practice in Indiana. If the physician performed a polypectomy, find out how she removed the polyp (biopsy or snare). In the case of multiple polyp removal, you should take stock of where on the colon each polyp was located and determine whether they were in separate locations or close enough to be considered one location. Then, Brasher says, check the method by which each polyp was removed.
 
Remembering these descriptions when looking at a chart will help you wade through ambiguous documentation:
 
CPT 45380 Cold Biopsy Forceps. These are disposable forceps that take tissue samples during an endoscopy. No electric current passes through them; hence, the term "cold." You cannot use these forceps to cauterize bleeding that the forceps may have caused. Brasher says that a partial polypectomy is usually a cold biopsy, whereas a total or entire procedure is done with a snare (43585), which lassoes the polyp.
 
 45381 With Directed Submucosal Injections. This new CPT code, 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance), became effective on Jan. 1. The "substance" could include saline, India ink, methylene blue, Botox or steroids. Make sure to verify coverage with your carrier, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.
 
45382 Control of Bleeding. No, it's not a trick: Many cauterization techniques that control bleeding can also be used for an ablation, and the code definition can also be confusing. But the defining factor is the diagnosis. For example, use 45382 when controlling bleeding from a polyp removed several days ago or for diverticulosis 562.12 (Diverticulosis of colon with hemorrhage) or 562.13 (Diverticulitis of colon with hemorrhage). Another application, Brasher says, is for angiodysplasia 569.85 (Angiodysplasia of intestine with hemorrhage).
 
Note: You cannot separately bill this code if the gastroenterologist has caused the bleeding during the colonoscopy.

 45383 Ablation. An ablation, normally performed during a follow-up colonoscopy, usually refers to a cauterization performed with an argon plasma coagulator (APC), heater probe, or other device that destroys any remaining polyp cells after a prior colonoscopy in which a larger polyp was removed by a snare.
 
When using any of these methods either for an ablation or to control bleeding, use 45383 (Colonoscopy ...; with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique). Be careful, though you don't apply this code when the doctor uses hot biopsy forceps, bipolar cautery, or snare technique for the ablation.
 
 45384 Hot Biopsy or Bipolar Cautery. When the surgery both removes and cauterizes a polyp simultaneously using hot biopsy forceps, you should use 45384 (Colonoscopy ...; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). Usually, these are smaller polyps. Also apply this code for bipolar cautery.
 
 45385 Snare Technique. Usually, gastroenterologists remove polyps especially larger ones during a colonoscopy with the snare technique, which employs an electrocautery snare, a heated wire loop that shaves off the polyp.

 In this situation, use 45385 (Colonoscopy ...; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Physicians theoretically could also use these snares, also called "hot snares," for cautery, but that's unusual. A snare has cautery on it, but you're not ablating the polyp, Brasher says.
 
But if two polyps are located right next to each other, for instance a small one right beside a large one and the physician spends a lot of time trying to remove the smaller polyp after removing the larger one, you should append modifier -22 (Unusual procedural services) so the physician is compensated and reimbursed for her time, Brasher says.

2. Adhere to Bundling and Modifier Policies

If you're going to bill 45384 or 45385, remember that National Correct Coding Initiative edits bundle 45380 into both of them.
 
Under certain circumstances, you can code both the biopsy and the polypectomy, however, if you append modifier -59 (Distinct procedural service) to the lesser-valued code. For example, if the physician performs a biopsy at one site (45380) and then removes a polyp at another site with a cold snare technique (45385), you would list 45385 first and append modifier -59 to 45380.   

Or if you take a biopsy at one site (45380) and remove a polyp at another site with hot biopsy forceps (45384), report 45384 first, followed by 45380 appended with modifier -59 to indicate both procedures.

3. Follow Billing-Frequency Rules

To avoid denials, make sure you only bill 45380 once during a colonoscopy, regardless of how many biopsies the gastroenterologist performs, and even if he does them in different areas (for instance, the transverse and descending colon). You can also bill 45381 only once, even though the physician may administer multiple injections during the procedure.
 
Likewise, no matter how many tumors, polyps or lesions the doctor treats by the same or 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.

 When the gastroenterologist uses different
techniques, though, you can bill multiple tumor, polyp or lesion removals, as long as you report each only once
per technique.