General Surgery Coding Alert

Question: Can I not report a biopsy (45380) on the same day as removal (for instance, 45384 and 45385)? My payer routinely rejects these claims. Should I append modifier 59?


Washington Subscriber

Answer: The National Correct Coding Initiative (NCCI) bundles biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with removal by hot biopsy forceps (45384, -with removal of tumor[s], polyp[s] or other lesion[s] by hot biopsy forceps or bipolar cautery) and snare technique (45385, -with removal of tumor[s], polyp[s] or other lesion[s] by snare technique).

In addition, NCCI bundles other biopsies (including 43202, 43239, 44361 and 45331) to their corresponding hot forceps and snare technique removals (43216, 43250, 44365, 45333 and 43217, 43251, 44364, 45338, respectively).

In a nutshell: You should not separately report biopsy and removal of the same polyp during the same session.

You can override the NCCI edits using modifier 59 (Distinct procedural service), but you should do this only if:

- the biopsy and removal take place during separate sessions, or

- the physician biopsies and removes separate polyp(s).

For example: The physician biopsies one lesion and removes a separate lesion. Report the biopsy with 45380 and the removal of the separate lesion with 45384 or 45385, as appropriate to the technique the surgeon uses. Because the removal code is the higher-valued procedure, you should append modifier 59 to the biopsy (45380) and include documentation that clearly states that the biopsy and removal(s) occurred at different sites.

If the surgeon biopsies and removes the same lesion, the procedures would not qualify as "distinct procedural services."  In such a case, you should code the removal only.