Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a proctosigmoidoscopy. During the procedure, he removed two polyps, one using hot biopsy forceps and another using the snare. I am of the opinion that we have to report this procedure using the code 45315 as it is a multiple polyp removal but my fellow colleague is saying that this is not correct. Please tell me whether or not this is correct? If not, then what is the right method to report this procedure?

Wisconsin Subscriber

Answer: When you are trying to report polyp removal by proctosigmoidoscopy, you need to look at a number of factors. You will have to look at the number of polyps that were removed and you will also have to look at the technique(s) that your gastroenterologist used to remove the polyp(s).

If your gastroenterologist removes a single polyp using cautery or hot biopsy forceps, then you should report the procedure using 45308 (Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery). If your gastroenterologist performed a proctosigmoidoscopy and during the procedure he removed a single polyp using the snare technique, the right way to report the procedure is by using 45309 (Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique). Note that these codes are for removal of a single polyp using either hot biopsy forceps, cautery or by snare technique. Similar codes for removal of single polyp or other lesions do not exist in other endoscopic families of codes.

But if your gastroenterologist removes multiple polyps by using hot biopsy forceps, bipolar cautery or by snare technique, you need to report the procedure using 45315 (Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique). Note that you can only report 45315 once irrespective of the number of polyps that your gastroenterologist removed during the procedure, and you should not use the code each time a polyp is removed during the session.

However, for reporting 45315, you need to note that the same technique should be used for the removal of each polyp or lesion during the proctosigmoidoscopy. In the scenario that you have described, you have mentioned that one of the polyps was removed by hot biopsy forceps and the other using the snare technique. Since two different techniques were used to remove the two polyps during the proctosigmoidoscopy, you cannot use 45315 to report the procedure.

So in this scenario, you will need to report the polyp removed using hot biopsy forceps with 45308 and the other polyp that your gastroenterologist removed using the snare technique with 45309.

Keep in mind: Correct Coding Initiative Edits (CCI Edits) indicate that code 45308 is a column 2 code for 45309. So you will also need to append the modifier 59 (Distinct procedural service) to 45308 to let the payer know that both the techniques were used during the proctosigmoidoscopy to remove the polyps. Provide proper documentation to show that the polyps were removed using different techniques, also mentioning the reason why two different techniques were employed by your gastroenterologist to justify these methods for polyp removal.