Outpatient Facility Coding Alert

Question: During a colonoscopy, the gastroenterologist used a snare to remove two polyps (one was in the ascending colon, the other in the descending colon). Then he biopsied a large mass in the sigmoid colon. How do we code this since he used two different techniques during the same procedure?

Wyoming Subscriber

Answer: You're correct in paying attention to the different techniques the surgeon used. When he uses different techniques to remove the polyps, you can submit the applicable code for each technique. In your scenario, report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the snare and 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the biopsy. Append modifier 59 (Distinct procedural service) to 45380 to indicate that the surgeon completed the biopsy at a separate site from the snare procedure.

Remember: If the physician removes multiple polyps using the same technique, you report a single code for the procedure (whichever applies to the technique employed). The code remains the same for any number of polyps removed.