Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a polyp removal, using the snare technique, in the ascending colon and then performed an ablation on another polyp in the same area in the ascending colon. Can I bill 45385 for the polyp removal by the snare technique and 45383 for the polyp removed using ablation? If so, should I use any modifiers on 45383?

New Jersey Subscriber

Answer: When your gastroenterologist removes a polyp using a snare, you will have to report the procedure using 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). When your gastroenterologist treats a polyp using ablation, you use 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) to report the procedure.

If multiple polyps are removed using snare technique from the same area, you will only have to use one unit of 45385 to report the removals that your gastroenterologist performed. The same holds good for multiple polyp treatments using ablation.

If multiple techniques were to be used in the removal of the polyps, as is in the case scenario that you have described, you can use different CPT^® codes to report the multiple removals only if different polyps were removed. Since you have clearly mentioned that your gastroenterologist removed the two different polyps with different techniques from the colon, you can report the procedure with two CPT^® codes.

As per the Correct Coding Initiative (CCI) edits, the CPT^® code 45385 is a column 2 code for 45383 with the modifier ‘1’ that means that you can use a modifier such as 59 (Distinct procedural service) to differentiate the two codes.