Gastroenterology Coding Alert

Question: How should I report multiple biopsies and/or polypectomies during the same session? For instance, should I report one unit of colonoscopy with biopsy ( CPT 45380 ) for each specimen taken, or one unit of polypectomy (45385) for each lesion removed?


New Mexico Subscriber
Answer: You should report only a single unit of 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) regardless of the number of biopsies the physician collects. The code specifically applies to -single or multiple- biopsies.

Similarly, you should report only one unit of 45385 (-with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) for multiple polyp removals.

In extreme circumstances (for instance, if the surgeon must remove 20 or more polyps, or must spend an extraordinary amount of time removing lesions), you may be able to gain additional compensation using modifier 22 (Unusual procedural services) with 45385. See -Modifier 22 Can Reward Extra Physician Effort- for complete information.