Gastroenterology Coding Alert

Question: I have a doctor who does endoscopic mucosal resection (EMR) for large polyps. He documents it as an EMR, though his technique is exactly the same as a lift and snare. Should I code this as a lift and snare instead, or does it have to be coded as an EMR?

AAPC Forum Participant

Answer: It’s hard to say for sure without more information. In order to code for an EMR, your provider would need to clearly document that the following three things occurred during the procedure:

1. Your provide used a technique to lift the lesion
2. Your provider performed demarcation of the lesion, often by creating a pseudopolyp out of tissue or any technique that allows clear visualization of the boundaries of the lesion
3. Your provider performed endoscopic snare resection but utilized a cap fitted device and/or specialized snare for the work. This latter requirement is not clear from the CPT^® descriptor — but is part of the physician work descriptor in the Relative Value Scale (RVS) Update Committee (RUC) database.

The documentation should clearly state that an EMR is used to remove the lesion(s). If the documentation supports these three components, you should report either 45390 (Colonoscopy, flexible; with endoscopic mucosal resection) or 45391 (Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures) depending on the size of the lesion. Report 45390 for lesions less than 20 mm, and 45391 for lesions larger than 20 mm. You also have the option of reporting 45349 (Sigmoidoscopy, flexible; with endoscopic mucosal resection) or 44403 (Colonoscopy through stoma; with endoscopic mucosal resection), which apply regardless of lesion size.

If the documentation does not support a true EMR procedure — but does support a lift-and-snare procedure— report 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and 45381 (Colonoscopy, flexible; with directed submucosal injection(s), any substance), which do not require modifier 59 (Distinct procedural service) for colon procedures. Note that a related procedure for even larger colon polyps, endoscopic submucosal dissection (ESD), requires use of unlisted codes to report.