You Be the Coder:
Is Injection With Removal Separate?
Published on Fri May 26, 2006
Question: During a colonoscopy, the doctor found a hemorrhaging polyp. To deal with the bleeding, he injected the polyp with epinephrine before removing it with the snare technique. Can I report the injection separately from the removal?
Pennsylvania Subscriber
Answer: Yes, you may report the injection separately.
For the colonoscopy with polyp removal, report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). You should also report the injection using 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance).
Important: Although you can report the injection separately with polypectomy, you may not report 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) separately with 45385. Control of bleeding is bundled to polypectomy at the same site.
