Gastroenterology Coding Alert

Question: Our office has not one, but two, coding questions about removing polyps via colonoscopy. Many times, our gastroenterologist will remove several polyps using the same technique. Less frequently, the gastro also treats polyps with different removal methods during the same visit. Can I report multiple codes in these office situations?

Mississippi Subscriber

Answer: When the physician performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you have to report codes according to the technique rather than the number of polyps.

Explanation: All polyp-removal codes are designed for use once per session regardless of the number of polyps removed.

Let’s say the gastro removes and cauterizes three polyps during a colonoscopy using a cautery forceps. You should report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s]), polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) once for the encounter.

In the above scenario, if the gastro removed one polyp with a large cup cold biopsy forceps, then removed the other two by snare technique, you would report:

• 45380 (Colonoscopy, flexible,  proximal to splenic flexure; with biopsy, single or multiple]) for the APC ablation.

• 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the polyp removals with the snare. 

• attach modifier 59 (Distinct procedural service) to 45380 to show that the biopsy removal and the snare technique removal were two distinctly different sites.

Remember: On the claim, also be sure your documentation supports two removal methods and explains why both methods were necessary.

If your gastroenterologist performed a colonoscopy through stoma, CPT® has designated three separate codes for removal of polyps. You will report:

• 44392 – Colonoscopy through stoma; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery

• 44401 – Colonoscopy through stoma; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre-and post-dilation and guide wire passage, when performed] 

• 44394 – Colonoscopy through stoma; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique.