Gastroenterology Coding Alert
Is Injection With Removal Separate?
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.
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