Wiki 2 methods for 1 colon polyp

[bchawkins@syix.com]

Please help me with the correct answer.

The operative report states "At proximal ascending colon, large colonic polyp abut 1.6-1.8 cm sessile polyp was seen. We experienced significant difficulty visualizing the whole polyp. We placed the patient on a supine position and applied abdominal pressure and finally we were able to place the polyp in a reasonable position for removal with snare. This polyp was removed in piecemeal fashion; however we still experienced removing the entire polyp completely and therefore, we also used hot biopsy forceps."

Would you code 45385 for just the snare (as the greater procedure) or would you code the hot biopsy forceps , 45384, since it sounds like the procedure which allowed him to complete the process?

Thanks,
Carrol

 

[Mary Rapp]

You would bill the greater procedure only because it was the same polyp.
If it was 2 different polyps in different locations, you could bill both.

 

[bwolfe1]

Snare technique (45385) has a higher value than the hot biopsy (45384). Also, append with modifier -22 for the extra work in positioning the patient and the abdominal pressure to access the polyp. Attach a copy of the operative note.