Gastroenterology Coding Alert

Question: Our GI physician identified a 10 mm semi sessile polyp in the ascending colon, and removed it with a hot snare, performing complete resection and retrieval. He performed fulguration to ablate the lesion by argon plasma, and place a hemostatic clip to prevent bleeding after the polypectomy. Can we code both 45385 for snare and 45388 for ablation for the same polyp?

Tennessee Subscriber

Answer: You may not use both 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and 45388 (Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)), because both services were performed on the same lesion.

If, however, the snared polyp was located at a different location than the ablated polyp, you could report both services with modifier 59 (Distinct procedural service) appended to 45385. That’s because the National Correct Coding Initiative (NCCI) bundles it into 45388 if you don’t use the modifier.