Gastroenterology Coding Alert

Question: We encountered a colonoscopy patient recently who required a laser tumor ablation. What is the procedure, and how should we code this?

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Answer: You will use colonoscopy code 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). You may have overlooked this code because the description seems at first glance to be a hodge-podge code for all methods of removing a polyp or mass that are not by snare technique or hot biopsy forceps. Because the term “ablation” simply means “to remove or excise,” most gastroenterologists use the term to refer to using argon plasma coagulators (APC), lasers, heater probes or other devices to cauterize a lesion, angiodysplasia, polyp or a previously removed polyp’s remnants to the point that it is destroyed.

Gastroenterologists may “ablate” the remnants of a large sessile (flat) polyp during a follow-up colonoscopy. If the polyp the physician removed during the initial colonoscopy was benign, the physician may perform a follow-up colonoscopy a few months later to make sure the entire polyp was removed. This is necessary because when the physician uses a snare to remove the initial polyp, there are often some cells still present that she must remove at a later date. The reason is that she has performed so much burning and removal during the initial visit, it isn’t possible to determine complete removal success.

Treating the site with APC, which uses argon gas to deliver thermal energy to a field of tissue adjacent to the probe, is one of the more popular methods for destroying the leftover cells. You should report cauterization done with APC, laser, or heater probe with the ablation code (45383). On the other hand, not all follow-up visits to remove the polyp remnants will include ablation. If the gastroenterologist uses the snare technique, you should report 45385 (... with removal of tumor[s], polyp[s] or other lesion[s] by snare technique). 

“There are also Correct Coding Initiative (CCI) edits which might apply to your claim. If your gastroenterologist performed a biopsy of the same lesion that is being ablated then the biopsy is included according to the bundling edit and should not be reported separately. Biopsies performed of other lesions can be reported using the modifier 59,” adds Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care.

Note: Your gastroenterologist is not limited to using these cauteries for ablation only. Your GI can use all of these mentioned methods (APC, laser, heater probe) to control bleeding too.