Part B Insider (Multispecialty) Coding Alert

Question: Recently, our gastroenterologist removed three polyps during a colonoscopy procedure using a cauterization. In another patient, he had to use a hot forceps for two polyps and an APC for another lesion in the same session. Can I report multiple codes in both these scenarios?

Answer: No. You cannot report multiple codes for the first case where the doctor performed a colonoscopy to remove more than one polyp using one method in the same session. The reason is that according to fair practice rules, you can only report a single code for polyp removal per session irrespective of the number of polyps removed. The same goes for removal of stents.

Case 1: In your first case, because the gastroenterologist removed and cauterized three polyps during a colonoscopy, you should report a single 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) for the procedure. 

Case 2: However, in the second case, the gastroenterologist removed two polyps with hot forceps, then ablated a lesion by an argon plasma coagulator (APC) technique presumably in a separate location. Therefore, you should:

• 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 of the lesion.
• report 45384 (…with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery) for the polyp removals with the hot forceps. 
• attach modifier 59 (Distinct procedural service) to 45384 to show that the APC ablation and the polyps removal were two distinctly different procedures. 

Remember: On the claim, also be sure your documentation supports two removal methods and explains why both methods were necessary. Since you have clearly mentioned that your gastroenterologist removed the two different kinds of polyps with different techniques from the colon, you can report the procedure with two CPT® codes.

As per the Correct Coding Initiative (CCI) edits, the CPT® code 45384 is a column 2 code for 45385 with the indicator ‘1,’ which means that you can use a modifier such as 59 (Distinct procedural service) to differentiate the two codes