Gastroenterology Coding Alert

Question: Are there specific times when a physician can use the ‘45383’, rather than ‘45385’? I read that if the polyp is small (1-3mm) and cannot be removed totally by snare, then ‘45383’ can be used.

Michigan Subscriber

Answer: The term “ablation” more commonly describes an erosive or corrosive destruction of a lesion by one of few methods, such as laser, cryotherapy, or chemotherapy. If the surgeon describes a polyp ablation by any of those methods, 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) would clearly be the best choice.

However, as per AMA which refers to information from the American Society for Gastrointestinal Endoscopy (ASGE), you cannot report 45383 when your gastroenterologist performs an ablation in addition to a snare technique.

Ablation of small polyp(s) is not often performed as a stand-alone procedure, but commonly will occur when using a snare to remove much larger polyps. When it’s not necessary to submit a tissue specimen and the same tool is used to expedite removal the physician work involved does not warrant reporting an additional CPT^® code. There is also the argument that this type of polyp would be amenable to removal by other techniques (biopsy forceps, hot biopsy, or bipolar cautery).

So, if your gastroenterologist performs an ablation for a small polyp and in the same session performs removal of other polyps by snare, you should not report 45383. Also, Correct Coding Initiative (CCI) edits bundle 45383 with 45385 with the modifier indicator ‘1,’ that specifies that you can unbundle the codes with a modifier such as 59 (Distinct procedural service) if appropriate documentation can be provided to separate the services. Ablation of a different type of lesion like an AVM (arterio-venous malformation) with bipolar cautery would be correctly coded using both codes along with a 59 modifier on the ablation code.

Otherwise, you can only report the procedure that your gastroenterologist performed with 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).