General Surgery Coding Alert

Question: Our surgeon performed a colonoscopy and a hot-forceps polyp excision. The op note describes how the surgeon first injected saline into the mucosa under the polyp to “lift” the polyp before performing the polypectomy. Can I separately report the injection?

Maine Subscriber

Answer: Some payers may pay for both procedures, which you would report as 45381 (Colonoscopy, flexible; with directed submucosal injection(s), any substance) for the injection, and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps) for the hot-forceps polypectomy. 

Medicare’s National Correct Coding Initiative (NCCI) edits do not bundle these two codes. That means you should be able to bill them separately without using any modifier to override an edit pair.

Payer discretion: Coders have reported that various payers either deny or accept this billing combination, so you may need to file an appeal if you get a denial, and try to get an explanation of the reason.

Even if the payer accepts both codes, you should expect a “multiple procedure” reduction is 50 percent of the allowable for the second-listed procedure. That means you should list first the code with the highest RVUs, which in this case, is 45384.