Gastroenterology Coding Alert

Question: Our provider examines the colon and rectum using a colonoscope and performs snare removal of multiple polyps. How do we code for this procedure?

Texas Subscriber

Answer: For removal of tumors, polyps, or other lesions by various techniques, you can use codes 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Report this code once no matter how many polyps the provider removes with the snare technique.

According to AMA, you may not report 45385 along with 45390 (Colonoscopy, flexible; with endoscopic mucosal resection) for the same lesion. Moreover, you also may not report 45385 along with 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).