Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a colonoscopy during which he removed a polyp by endoscopic mucosal resection and then placed a hemoclip on the defect. There was no bleeding involved. Now he wants me to find a code for the clip that he placed during the procedure. What code should I report?

North Carolina Subscriber

Answer: Endoclips or hemoclips are just a closure tool that is used as part of a procedure. There are no separate CPT® codes for the placement of an endoclip during a procedure. As per your description for the procedure, your gastroenterologist used the hemoclip to cover the defect that was formed due to the resection procedure that he performed to remove the polyp. As it is part of the procedure, you do not have the ability to report the placement of the hemoclip separately using a control of bleeding code such as 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]).

Instead, you will only have to report the procedure code that your gastroenterologist performed. So, you will only have to report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).