Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a colonoscopy. During the procedure, using the snare, he removed two polyps, one in the ascending colon and the other in the descending colon. He also conducted a biopsy of another large mass that was present in the sigmoid colon. How should I report this as two different techniques have been employed?

Florida Subscriber

Answer: If multiple polyps are removed by using the same technique, you only code once (with the correct code that is applicable to that particular technique), irrespective of the number of polyps that are removed. But, if the number of polyps are so high that the gastroenterologist used more than double the amount of time that is usually taken for the removal, you will need to add the modifier 22 (Increased procedural services) to the code. Be cautious while using modifier 22. If physician took some amount of time, it doesn’t warrant the use of modifier 22. If clinical information such as extra time and increased work (more than 50% of the actual time) is exactly documented in the patient’s medical records then only you are eligible to append modifier -22 to the usual procedure code.

If different techniques were used to remove the polyps, then the appropriate code for each technique used can be reported. In this case, you can use 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the snare and 45380 (Colonoscopy, flexible; with biopsy, single or multiple) for the biopsy. A modifier 59 should be added to the second code to indicate that the biopsy was performed at a separate site from the snare procedure.