General Surgery Coding Alert

Question: How can I report colonoscopy with snare polypectomy at the cecum and biopsy at the sigmoid?


Michigan Subscriber
 

Answer: You should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the polypectomy and 45380 (... with biopsy, single or multiple) for the biopsy.

And you should append modifier 59 (Distinct procedural service) to 45380 to differentiate it from 45385 at a separate location. If you leave off the 59, the payer will bundle the procedures.

Although you may report both 45385 and 45380 in this case, the -multiple endoscopy- rule applies. This means that the payer will reimburse for the highest-paying procedure at 100 percent of the usual fee rate but reduce the value of the secondary procedure by an amount equal to payment for the -base- endoscopic procedure. The payer's thinking in this case is that because both procedures -include- a basic approach, you should only be paid for that approach once.

For example: You will receive full value for the endoscopic polypectomy (5.3 physician work relative value units, or about $201 on average for Medicare payers). For the biopsy, you will receive the standard fee (4.43 work RVUs) minus the value of the endoscopic base code for both procedures (45378, -diagnostic-, valued at 0.96 work RVUs), or 3.47 RVUs (about $131 on average for Medicare payers).