Advanced Search

General Surgery Coding Alert

You Be the Coder:

Do Multiple Polyps Mean Multiple Codes?

Published on Sun Feb 27, 2005

Question: Often, the surgeon will remove several polyps via colonoscopy using the same technique. Less frequently, she also treats polyps with different removal methods during the same visit. Can I report multiple codes in these office situations?

Missouri Subscriber

Answer: You should report all polyp-removal codes once per session, regardless of the number of polyps the surgeon removes. Therefore, when the surgeon performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you cannot report multiple codes.
 
For instance, if the surgeon removes and cauterizes three polyps during a colonoscopy, you should report a single unit of 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) to describe the encounter.
 
In contrast, if the surgeon ablated one polyp with an argon plasma coagulator (APC), then removed the other two by snare technique, you would:
 

  • report 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for the APC ablation
     
  • report 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the polyp removals with the snare
     
  • attach modifier -59 (Distinct procedural service) to 45385 to show that the APC ablation and the snare removals were two distinctly different procedures.

     Be sure your documentation supports the two removal methods and explains why both were necessary.

    • Other Articles in this issue of

    General Surgery Coding Alert

    View All