Wiki Billing 45381 with 45385

[cbtucaz]

If the doctor removes a polyp by snare technique and uses a saline-lift injection to help with the snare, is it appropriate to bill for both the 45385 and 45381? I've gotten conflicting information on whether the injection is acutally just a component of the snare removal or can be reported separately.
Thanks!

 

[plynn]

According to the 2011 General Surgery / Gastro Coding Companion;

45381

"The physician performs flexible colonoscopy of the proximal to splenic flexure and injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. The physician inserts the colonoscopy through the anus and advances the scope as far as the splenic flexure of the colon. The lumen of the colon is visualied. Submuscosal saline injection, for instance, may be done efore polypectomy using snare and electrocautery to greaty enhance the effectiveness of resection for large sessile colorectal polyps"

Sounds to me like it is billable ... I did not check CMS CCI Edits.

Hope this is helpful

plynn

 

[russmam]

This is coded 45385 with 45381
No modifiers required