Gastroenterology Coding Alert

Question: Our gastroenterologist performed an endoscopy with submucosal injection procedure during the same session as another procedure and clearly documented both services, but our office manager said we can't report the injection separately. Is this accurate?

Codify Subscriber

Answer: In some situations, you can collect for both services. For instance, if your physician performs a polypectomy (such as 45385, Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and tattooing for subsequent resection during the same session, you can report both procedures.

Sometimes, the physician may inject the base of a polyp with saline (45381, Colonoscopy, flexible; with directed submucosal injection(s), any substance), and then remove the polyp by snare in piecemeal fashion (45385). The physician will then inject India ink at the polypectomy site to be able to identify the location in the future. You can report both 45381 and 45385 for the service, and no modifier is necessary since the Correct Coding Initiative doesn't bundle the codes.