General Surgery Coding Alert

Question: During a colonoscopy, our surgeon documented removing a large colon polyp using endoscopic submucosal dissection (ESD). Should I report this as 45390?

Ohio Subscriber

Answer: No, you should not report 45390 (Colonoscopy, flexible; with endoscopic mucosal resection) for endoscopic submucosal dissection (ESD). Although similar, the submucosal dissection is a different procedure.

Depending on the payer, you may report the service using HCPCS Level II code C9779 (Endoscopic submucosal dissection (esd), including endoscopy or colonoscopy, mucosal closure, when performed). For other payers you may need to use an unlisted CPT^® code, such as 45399 (Unlisted procedure, colon).

To use the endoscopic mucosal resection (EMR) code such as 45390, the note should indicate the following steps:

• Your surgeon used a technique to lift the lesion;
• Your surgeon performed demarcation of the lesion, often by creating a pseudopolyp out of tissue, or any technique that allows clear visualization of the boundaries of the lesion; and
• Your surgeon performed endoscopic snare resection but utilized a cap fitted device and/or specialized snare for the work. This latter requirement is not clear from the CPT^® descriptor — but is part of the physician work descriptor in the Relative Value Scale (RVS) Update Committee (RUC) database.

Note: CPT provides other codes for EMR:

• 45349 (Sigmoidoscopy, flexible; with endoscopic mucosal resection)
• 44403 (Colonoscopy through stoma; with endoscopic mucosal resection)