Gastroenterology Coding Alert

Question: Our gastroenterologist recently removed three polyps in the cecum from a patient. He removed two of the polyps by biopsy forceps and then used an Argon probe to ablate the rest of the polyps. The third polyp was removed using snare polypectomy followed by the use of the Argon probe for ablation. How do I report this procedure that my gastroenterologist performed?

Wisconsin Subscriber

Answer: When many polyps are removed during a colonoscopy procedure using the same method, then only one unit of the code that corresponds to the method used is reported for the procedure that your gastroenterologist performed. This is so because the descriptors for all the methods of removal including snare technique (45385), biopsy (45380), hot biopsy forceps (45384), or bipolar cautery forceps (45384) all represent a single code for removal of a single or multiple polyps, tumors or any other lesions.

However, if the number of polyps or lesions are so high that your gastroenterologist took a very long time to complete the procedure (more than 150 percent of the usual time), then you can append modifier 22 (Increased procedural services) to the procedure code to indicate that your gastroenterologist took more time to perform the procedure. Provide adequate documentation regarding the time taken and the number of polyps that were removed during the procedure.

But if the polyps that your gastroenterologist removed during the session were removed by different techniques, then the different techniques should be reported separately. The modifier 59 (Distinct procedural service) should be appended to the lesser valued procedure to indicate that different techniques were performed to accomplish the task.

Some lesions are not amenable to complete removal with any of the above techniques and the tissue must be ablated to assure the lesion is adequately destroyed.  This can be done with a number of methods including heater probe, bipolar cautery probe, argon laser, and others but not the methods mentioned in the first paragraph.

Code it: In the scenario that you have described, you have three methods that your gastroenterologist performed to biopsy, remove and or ablate the polyps i.e. snare polypectomy, biopsy forceps and Argon probe ablation. So you will have to use 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and with modifier 59 to report this procedure. The ablation of the tissue (tumor, polyp, or other lesion) can be performed regardless of whether a sample was obtained with a biopsy forceps before the ablative device is applied but the biopsy should not be reported in addition to the ablation on the same lesion.  (CPT Assistant, January 2004).