Wiki Polyp Removal by snare, and ablation

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Atillema12

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Hi,

I need advice on a polyp removal. The following shows a polyp removed by snare and also fulguration on that same lesion. I am being advised to code both 45385 for snare and 45388 for ablation. Would both be coded for same location?

A 10 mm polyp was found in the descending colon. The polyp was semi-pedunculated. The polyp was removed with a
saline injection-lift technique using a hot snare. Resection and retrieval were complete. Fulguration to ablate the lesion by
argon plasma was successful. To prevent bleeding after the polypectomy, one hemostatic clip was successfully placed.
There was no bleeding at the end of the procedure.

Any help is appreciated. Thank you
 
Only one code can be reported for this. Its mutually exclusive per NCCI so report the more complex code for more than 1 technique on same polyp.
 
Polyp removal using saline inj-lift technique & snare is 45390

Regarding:
"The polyp was removed with a saline injection-lift technique using a hot snare. Resection and retrieval were complete...."

Just wanted to add that actually this technique fits the definition of CPT 45390 "Colonoscopy, flexible; with endoscopic mucosal resection". :)
 
Per CPT you can bill these two codes together for the same lesion. There is not an excludes note for these two codes together. Furthermore, NCCI Edits states they can be billed together w/ a 59 mod on 45385. These are separately identifiable procedures.
 
CodingKing said:
Only one code can be reported for this. Its mutually exclusive per NCCI so report the more complex code for more than 1 technique on same polyp.
Click to expand...
NCCI does say they are mutually exclusive if reported w/out a 59 mod. Since the CPT book does not have an Excludes note for these two codes they can be billed w/ a 59 mod.
 
DianeMS said:
Polyp removal using saline inj-lift technique & snare is 45390

Regarding:
"The polyp was removed with a saline injection-lift technique using a hot snare. Resection and retrieval were complete...."

Just wanted to add that actually this technique fits the definition of CPT 45390 "Colonoscopy, flexible; with endoscopic mucosal resection". :)
Click to expand...
EMR is what came to mind immediately for me as well.
 
soopersue said:
This does not qualify for 45390, no demarcation of margins noted and it is not called an EMR in the statement.
Click to expand...
I am not sure what needs to be documented for demarcation of margins specifically. Are you aware of any procedure report where this is specifically mentioned? Please do share examples if you have any.

Also, not sure that it needs to be called out as an EMR for it to be billed as such.

This is an old reference, not sure if there is a newer version, but it explains Injection- assisted EMR. "Staining dye (ie, diluted indigo carmine or methyleneblue) is frequently added to the injection solution to facilitate identification of the lateral and deep margins of the target lesion before and during the resection process."

 
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