Unfortunately, these two codes are often denied/pended even with the appropriate modifier. For the claim to be paid, it will have to be appealed. The payer is looking for documentation to include a separate lesion treated with a separate technique which includes the instrument used to treat the lesion(s). If that information is not contained within the endoscopy report, the payer will most likely only pay for one technique. Use of the XS modifier in place of modifier 59 also is recommended since that modifier is more specific and is also accepted by the majority of commercial payers, not just Medicare. It is also important to link the diagnosis as well as enter locations into the comment field (Box 19) for each technique to support "separate lesion" designation. For supporting documentation, please refer to NCCI policy, chapter 6, section H, #25 which states:
The NCCI PTP edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by using modifier 59 or -X{EPSU}. Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier 59 or XE is only appropriate if the two procedures are performed at separate patient encounters.