Gastroenterology Coding Alert

Question: What modifier should I use when a gastroenterologist performs colonoscopy, and does more than one kind of polypectomy (i.e., 45385 and 45384)?

Utah Subscriber

Answer: Mainly, you should just use modifier 59 (Distinct procedural service) appended to 45384 (Colonoscopy with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). Both 45385 (Colonoscopy; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and 45384 include the value of a diagnostic colonoscopy.

In this case, you would choose 45385 (with the higher RVU), and place it in the primary position, while 45384 goes in the secondary position. The lesser value code (45384) will be paid at full price minus the cost of the diagnostic service. Appending modifier 59 would tell the insurance carrier that the lesions were different and were removed from different areas of the colon.

Exception: Wellcare requires providers to use modifiers 51 (Multiple procedures) and 59. A few companies, however, will not pay both no matter what.

Good idea: You may use different ICD-9 codes when you can.

For example, you may report 211.3 (Benign neoplasm of colon) for hot forceps removal in ascending colon, and 211.4 (Benign neoplasm of rectum and anal canal) for rectosigmoid. Sometimes it works if a practice would use operative notes and pathology reports to show the location and status of the lesion.