Same-Polyp Intervention? Turn to 45383 and 45381

As a gastroenterology coder, you may find yourself bowled over by coding situations such as these: The olympus scope was passed in the transverse colon. Outstanding prep. The lesion itself was at about 9 centimeter in the rectosigmoid or upper one third of the rectum really. With the rotatable snare, the base was encircled, and the polyp removed, and then one more small piece that was still on the wall was removed, thus, removing the entire lesion. This was retrieved, and put in a pathology bottle. After this, the area was re-examined. Since there was a diagnosis of dysplasia, it was elected to use the APC with 360 head post polypectomy setting which was done, and the entire area was APC’d under narrow band light. This was removed, the Argon removed, and then a tattoo was a SPOT material was used and photographs were clicked.

As such, what codes should you use to report this procedure?

Well, it appears the snare and APC intervention are on the same polyp/lesion. According to the report, the scope was passed only to the transverse colon; as such, if the procedure was planned as a sigmoidoscopy then you would use CPT codes from the flexible sigmoidoscopy family of codes even if the scope went beyond the splenic flexure. If the procedure was planned as a colonoscopy, then you should bill these codes on your claim:

  • For code 45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
  • For code 45381 -Colonoscopy, flexible, proximal to splenic flexture, with directed submucosal injection[s], any substance.

You should not go for 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) as correct coding initiative edits bundle this code into 45383. The relative value units for 45385 (15.69 relative value units for non-facility) are lower than that for 45383 (16.72 relative value units for nonfacility); as such using the latter code will bring you more reimbursement: $568.09 (relative value units) multiplied by 2011 conversion factor of 33.9764). In this situation, you cannot unbundle the edit by using modifier 59 since interventions are on the same polyp. You’d bill the tattooing with 45381.

For more on this and for other medical coding updates pertaining to gastroenterology coding, sign up for a good medical coding guide like Supercoder.