Gastroenterology Coding Alert
Injection Isn't Bundled to Colonoscopy
Question: During colonoscopy, the gastro-enterologist found a polyp in the cecum. He removed the polyp using snare technique. During the same session, while investigating the transverse colon, the gastro-enterologist sees a suspicious area that he injects with India ink. How should we code this?
Maryland Subscriber
Answer: You should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the colonoscopy with polyp removal. You may also report 45381 (... with directed submucosal injection[s], any substance) to represent the injection.
The National Correct Coding Initiative (NCCI) does not bundle 45381 to 45385, and therefore you shouldn't need to add modifier 59 (Distinct procedural service) to 45381. The polyp removal and India-ink injection are separate procedures.
If your payer rejects the claim, be sure to point to the NCCI as evidence that these procedures are not bundled.
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