Gastroenterology Coding Alert

Question: Our gastroenterologist recently began a screening colonoscopy on a low-risk Medicare patient. During the procedure, the gastroenterologist found a polyp, which he ablated using bipolar cautery. Should we still report the G code for a screening colonoscopy, a regular CPT code, or both?


Ohio Subscriber
Answer: You should definitely not report two codes for this encounter. If your gastroenterologist starts out performing a Medicare screening colonoscopy and aborts the screening to perform a procedure, always report the procedure code and leave G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) behind.

On the claim, 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) for the procedure.

Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, CMSCS, an independent coding consultant in Marietta, Ga.