Gastroenterology Coding Alert

Question: Our gastroenterologist attempted polyp removal using a hot snare. However, the procedure was stopped midway and resection was not possible. Can I code this with 43239 with modifier 52 appended?

California Subscriber

Answer: Since your gastroenterologist attempted polyp removal using a snare, you cannot code it with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Instead, you need to code it with 43251 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Modifier 52 (Reduced services) is appended for a procedure that has been partially eliminated or reduced. It is not an appropriate modifier for a discontinued procedure. When a procedure is discontinued because of any extenuating circumstances that might be detrimental to the patient's well being, you should use the modifier 53 (Discontinued procedure).If the procedure is being conducted in an out-patient facility or at an ambulatory surgery center, you should use modifier 74 (Discontinued out-patient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia).

So, the right code to go for in this circumstance will be 43251-53.

Know the procedure: Under anesthesia, the gastroenterologist will introduce a scope through the mouth to visualize the gastrointestinal tract to locate lesions such as polyps. Once the lesion has been isolated and marked, the gastroenterologist will introduce a snare (wire loop) which is then passed over the lesion. The snare sheath is pushed to fit snugly to the base of the lesion. After this, the lesion is subjected to current of low power that helps in cutting off the stalk of the lesion. This also aids in minimizing bleeding in the site as it aids in blood coagulation.