Revenue Cycle Insider

Question: I have a gastroenterologist that wants to bill for each polyp removed. Any advice on how to bill for the below scenario?

A. Two 4 mm polyps in the cecum; sessile morphology; cold snare polypectomy performed, polyps retrieved.

B. Two 2 mm polyps in the cecum; sessile morphology; cold forceps polypectomy performed, polyps retrieved.

C. 5 mm polyp in the sigmoid colon; sessile morphology; cold snare polypectomy performed, polyp retrieved.

D. 2 mm polyp in the sigmoid colon; sessile morphology; cold forceps polypectomy performed, polyp retrieved.

Any help would be appreciated!

AAPC Forum Subscriber

Answer: You should code by the instrumentation the physician used, not per polyp. In this case, you should report the following:

• 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)
• 45380 (Colonoscopy, flexible; with biopsy, single or multiple) with modifier 59 (Distinct procedural service) if the patient has commercial insurance, or 45380 with modifier XS (Separate structure) for Medicare

If the colonoscopy started as a screening, add modifier 33 (Preventive services) for commercial payers and modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) for Medicare.

You can’t code the same instrument twice in the same surgical session. So, if the doctor removes five different polyps from five different locations but uses a snare to remove all of them, you would only code a single unit of 45385.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor