Part B Insider (Multispecialty) Coding Alert

Question: Our physician performed a colonoscopy and removed a polyp by hot snare. He completely removed the polyp but could not retrieve it after resecting it. Can we still report 45385 for this service without having the polyp as evidence?

Answer: Unless your payer policy says otherwise, you can report this service with 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). The physician did use the snare technique to remove the polyp, so he fulfilled the code’s requirements.

However, there should be no pathology charge for this visit since the physician will not be examining the polyp. Therefore, you won’t be able to tell the patient or the payer if the polyp was adenomatous or hyperplastic.