General Surgery Coding Alert

Question: During a screening colonoscopy, the surgeon biopsied a suspicious area in the descending colon, and removed a polyp using hot biopsy forceps in the transverse colon. Can we separately code the procedures?

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Answer: Yes, with the documentation of distinct anatomic sites, you can bill both 45380 (Colonoscopy, flexible; with biopsy, single or multiple) and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps).

Because the National Correct Coding Initiative (NCCI) bundles 45380 into 45384, you’ll need to use an appropriate modifier to override the edit pair. For instance, you may use XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure), or if your payer prefers, 59 (Distinct procedural service).

Tip: Because the removal code is the higher-valued procedure, you should append the modifier to the biopsy (45380) and include documentation that clearly states that the biopsy and removal(s) occurred at different sites for different lesions.