Gastroenterology Coding Alert

Question: My physician isn't satisfied to report 45385 just once if he removes several polyps during the same session. Is he correct to want to report multiple units? If not, how can I convince him that we should stick with one unit of 45385 for multiple removals?

Michigan Subscriber

Answer: This is an all-too-common area for confusion, but CPT instructions are clear: Colonoscopy (45385) applies for -removal of tumor(s), polyp(s) or other lesion(s) by snare technique.- By using the plural (for instance, -tumor[s]-), the descriptor specifically notes that you should apply the code only once per session for all lesions, etc., that the physician removes during the same session.
 
And CPT Assistant July 2004 states that 45380, 45384 and 45385 define different techniques and that you can use it only once for a single colonoscopy procedure regardless of whether the physician uses the technique on multiple polyps or multiple times on a single polyp.
 
In rare cases, such as when the physician encounters an unusually high number of polyps (for example, a dozen or more), you may be justified to report 45385 with modifier 22 (Unusual procedural services).
 
If you wish to file such a claim, you-re going to want bulletproof documentation, including a full note that describes the procedure in detail, as well as the time the physician had to devote to the procedure and how this differs from a -typical- procedure of the same type.
 
Also include a cover letter explaining the unusual nature of the procedure in brief (for example, -The physician had to remove 15 polyps. Typically he must remove only 1-3.-) and asking for increased reimbursement.
 
You can report separate removal techniques during the same session, if required. Therefore, you can report 45385 and 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) during the same session if the GI physician uses these removal methods on separate sites.
 
But documentation should support the necessity for using the different methods, because payers could see such coding as a ploy to increase reimbursement without medical necessity.