Gastroenterology Coding Alert

Question: Our office has 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?

Missouri Subscriber

Answer: When the physician performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you cannot report multiple codes

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

Suppose the gastro removes and cauterizes three polyps during a colonoscopy using a hot biopsy 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 ablated one polyp with an argon plasma coagulator (APC), then removed the other two by snare technique, you would:

• report 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) for the APC ablation.

• report 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the polyp removal with the snare.

• attach modifier 59 (Distinct procedural service) to 45385 to show that the APC ablation and the snare technique removal were two distinctly different procedures.

Remember: On the claim, also be sure the documentation supports two removal methods and explains why the physician needed to perform both methods.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.