Internal Medicine Coding Alert

Published on Thu Mar 17, 2011 PDF

Question: How should I report the procedure based on this physician's notes:

"Patient with history of colon polyps; Ileocecal valve was prominent and somewhat displaced and was biopsied extensively. Sessile polyps removed by snare from transverse and descending colon"

Michigan Subscriber

Answer: Code the procedure using the following:

• 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for colonoscopy with removal or polyps using snare technique;
• CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to describe colonoscopy with biopsy;
• Modifier 59 (Distinct procedural service) attached to 45380 to indicate that it is a different procedure not ordinarily encountered or performed on the same day.

Your ICD-9 report should include:

• V12.72 (Personal history of colonic polyps) to indicate that the patient has a history of colon polyps;
• 211.3 (Benign neoplasm of colon) describes the neoplasm in the patient's colon; and
• 569.89 (Other specified disorders of intestines) to represent the displaced Ileocecal valve.

What if: If many polyps exist in various regions -- and the physician spends a lot of time removing the polyps -- you should report 45385 and attach modifier 22 (Increased procedural services) so the physician is compensated and reimbursed for his time. Often, double the usual amount of time is reason enough to use modifier 22. You should expect to need to appeal the claim using the medical records of the procedure and a paper claim. You should not expect a significant increase in the payment.