Gastroenterology Coding Alert

Question: Our physician performed a colonoscopy and polypectomy on a 55-year-old patient. At a different site from the polypectomy, he took a biopsy of a lesion. Can I report both procedures with modifier -59 (Distinct procedural service)?

Arizona Subscriber

Answer: When a gastroenterologist biopsies and removes the same polyp, the National Correct Coding Initiative bundles the procedures. However, you may report both when the physician removes a polyp by one technique and biopsies a separate lesion.

For example, a gastroenterologist removes one polyp using hot biopsy forceps and biopsies a separate lesion using cold forceps. You would report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesions[s] by hot biopsy forceps or bipolar cautery) and 45380 (... with biopsy, single or multiple).

You should append modifier -59 to the lower-valued procedure, in this case 45380, to indicate that the removal occurred at a separate site from the biopsy. However, if you biopsied the polyp using the cold forceps and subsequently removed the same polyp using hot biopsy forceps, you can charge only for the hot biopsy.