Gastroenterology Coding Alert

Question: I have recently received denials for second procedures using 45385, and 45384 with CPT 45380 . Until now they were paid using multiple-procedure rules. Were the CCI edits changed recently? Should I use modifier -59?

Washington Subscriber

Answer: The latest version (8.1) of the Correct Coding Initiative (CCI) bundled biopsy codes (43202, 43239, 44361, 45331, 45380) with removal by hot biopsy forceps (43216, 43250, 44365, 45333, 45384) and the removal by snare technique codes (43217, 43251, 44364, 45338, 45385). Although CCI 8.1 was the first published announcement of the bundling, the edits were part of Medicare's unpublished October 2000 edits.

The CCI edits designate the biopsy codes with a superscript of 1, which means modifier -59 (Distinct procedural service) can be used to override the edits. If the procedures constitute a different service, you may be able to report both procedures using modifier -59.

If the physician biopsies one lesion and removes a separate lesion, you should report the biopsy with 45380 (Colonoscopy; with biopsy, single or multiple), and the removal of the separate lesion with 45384 ( with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) or 45385 ( with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). The removal codes have higher relative value units (RVUs) 45384 has 4.70 work RVUs, and 45385 has 5.31 work RVUs than the colonoscopy with biopsy code. Therefore, you should bill 45384 or 45385 first and then 45380 appended with modifier -59.

If the gastroenterologist biopsies and removes the same lesion, the procedures would not qualify as distinct procedural services. You should code the removal only.

Some carriers, such as Trailblazer Health Enterprises Inc., created local medical review policies (LMRPs) mandating other rules. In its LMRP effective October 1996, TrailBlazer, Maryland's Medicare Part A carrier, states, "When a claim is submitted for a biopsy(s) or a polyp(s), the only code necessary for care rendered is CPT 45380 or 45385. Although the provider may continue to state the number of biopsies or polyps removed, benefits are limited to one biopsy and/or one polypectomy, and reimbursement is all-inclusive in the primary endoscopic procedure. Separate benefits for additional biopsies/ polypectomies are not available."

You should ask your carrier for any policies on 45385, 45384 and 45380. If your carrier bundles the biopsy and the removal, using the higher-RVUs rule, select the appropriate removal code.