Wiki Coding 45380 & 45385

[lblouin1069]

Good Morning...Quick question, would appreciate any help!!

Scenario: During diagnostic colonoscopy doctor finds 4 polyps in the descending colon. They are removed by cold biopsy.
He than finds 1 single polyp in the descending colon and this is removed by snare technique.

What codes would you use and why? We have conflicting answers and I wanted to reach out and see if we could get any input off the AAPC forum. Thanks in advance!!

 

[nsteinhauser]

If this is a commercial plan, then:
45385
45380 - 59
The location in the colon is not going to directly affect your choice of cpt codes. That would directly affect your ICD-10 diagnosis codes - IF the pathology came back as adenomatous polyp versus hyperplastic polyp. The diagnosis codes for adenomatous polyps are based on their location in the colon. The hyperplastic polyp diagnosis is just one diagnosis, not based on location in the colon.
For CPT usage, you can code separately for separate instrumentation - but only once per instrument per surgical session, and with using a modifier (Typically this means -59 for commercial plans and -XU for Medicare plans. But every payer has different rules for modifier usage so you'll need to be aware of those.) AS LONG AS the instruments are not used on the same exact polyp.
For instance -
Doctor uses a snare to resect 3 different polyps = 45385 coded once (not 3 times) Your example = doctor also resects a different polyp using cold biopsy forceps = then you would also code a 45380 with a modifier.
If the doctor first attempted to resect a polyp with a snare - but then had to go back to that SAME polyp site and use biopsy forceps to resect the remainder of the polyp, you can't use both the 45385 and the 45380 because it is the same polyp.
Hope this helps.

 

[lblouin1069]

Thank you so much for the awesome explanation and quick reply to my coding polyps correctly, question. Have a great day and thanks again, this really helped!