Gastroenterology Coding Alert

Question: During a colonoscopy within the sigmoid colon, the gastroenterologist biopsied and then removed with the snare technique a long, loose polyp on a stalk. When filing the claim, should I report the colonoscopy with the snare technique, the colonoscopy with biopsy, or both?

Mississippi Subscriber

Answer: You should report only 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

When a gastroenterologist biopsies the same mass that he removes during a colonoscopy, you cannot report a colonoscopy with biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) because the biopsy is a component of 45385.

If a gastroenterologist removes a polyp during a colonoscopy and does a biopsy on a separate lesion that he doesn't remove, you can report 45385 and 45380 with modifier 59 (Distinct procedural service) appended.