Gastroenterology Coding Alert

Question: Prior to taking biopsy samples of polyps, our gastroenterologist injected epinephrine to the site to prevent bleeding. Can this be coded with 45381? There was no bleeding during or after the procedure.

Ohio Subscriber

Answer: The injection of epinephrine to the site prior to taking biopsy samples will be considered as part of the biopsy procedure and should not be coded under 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s] any substance), as this forms an integral part of the actual procedure itself and cannot be considered as a separate procedure.

The code 45381 is more apt in situations wherein your gastroenterologist is injecting a substance like India ink to help mark the polyp or lesion or injecting saline or hyaluronic acid to create a lift or pillow. This will enable easy removal.

But, if your gastroenterologist's sole intention of using an injection was control of bleeding in the site, then you could use 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) and not 45381. This assumes that the bleeding was not caused by the gastroenterologist during the procedure.