General Surgery Coding Alert

Question: Our surgeon performed a colonoscopy, removing one polyp, but he also documented a submucosal injection. Can we bill for both services?

Texas 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 injects ink for tattooing for subsequent resection during the same session (45381, Colonoscopy, flexible; with directed submucosal injection(s), any substance), you can report both procedures.

CCI review: Before reporting codes like this together, you should always check Correct Coding Initiative (CCI) or other edit packages that your payers use to define proper coding. In this case, CCI doesn't bundle 45381 and 45385. That means you can report the codes together with no restriction if the medical record indicates necessity for both procedures, and the op report documents that the surgeon carried out both procedures.

Expect pay reduction: Because your surgeon performed two scope procedures, you can expect the multiple endoscopy payment reduction to apply to the fees you'll receive. This calculation takes out the base shared endoscopy fee (diagnostic colonoscopy, in this case) from the second procedure. The payment reduction avoids duplicate payment for the shared portion of the procedure.