Gastroenterology Coding Alert

Question: The provider identified a 10 mm semi sessile polyp in the ascending colon, and removed it with a hot snare, performing complete resection and retrieval. He did fulguration to ablate the lesion by argon plasma, and place a hemostatic clip to prevent bleeding after the polypectomy. Can we code both 45385 for snare and 45388 for ablation for the same polyp?

Minnesota Subscriber

Answer: You may not use CPT^® Code 45385(Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and 45388 (Colonoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed), because both services were performed on the same lesion. You could use both codes and apply a -59 modifier if the snared polyp was at a different location to the ablated polyp.