Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a colonoscopy. The operative report read like this:

Multiple small and large-mouthed diverticula were found in the sigmoid colon. Estimated blood loss: none. A pedunculated polyp was found in the sigmoid colon. The polyp was 20 mm in size. The polyp was removed with a hot snare. Resection and retrieval were complete. Estimated blood loss: 25 mL requiring treatment with epinephrine and 4 clips. A sessile polyp was found in the sigmoid colon. The polyp was 4 mm in size. Biopsies were taken with a cold forceps for histology. Estimated blood loss: none. Multiple small (>5mm) polyps were found in sigmoid and rectum that were not biopsied. Non-bleeding internal hemorrhoids were found during retroflexion.

Let me know what the correct way of reporting the procedure is.

New Jersey Subscriber

Answer: Note that your gastroenterologist used two different procedures to remove the polyps, namely, hot snare and cold biopsy forceps. Since two different procedures were used to remove the polyps, you will have to report both the procedures. So, you will have to report the polyp removal with hot snare using 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). The polyp that your gastroenterologist removed using cold biopsy forceps will have to be reported with 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

But, as per CCI edits, the code 45380 is a column 2 code for 45385. In order to report both these procedures, you will have to add a modifier to differentiate that the two services your gastroenterologist provided were performed at separate sites in the colon. So, in order to report both these procedures together, you will have to use the modifier 59 (Distinct procedural service) and append it to 45380. So, the correct way of reporting the procedure is 45385 and 45380-59.

Remember: If all the polyps were removed using only the hot snare, then you will not report the procedure twice as the descriptor for 45385 clearly states that it includes multiple removals. The same holds good for multiple removals with biopsy forceps. However, if the number of polyps are so high that your gastroenterologist had to spend more than fifty percent of the time that is used for a typical procedure, then you can add the modifier 22 (Increased procedural services) to indicate that the procedure took more time to warrant additional reimbursement. However, the documentation should clearly show that more time was required for the removal of the large number of polyps to avoid denial of the claim.

What about the bleeding that required epinephrine and 4 clips? You might ask why you can't use code 45381 (Colonoscopy, flexible, proximal to splenic flexure; with injection) or code 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator])? Correct Coding Edits state that services to stop bleeding are included in the procedure code if caused by the removal of a polyp with a snare or caused by a biopsy.