Gastroenterology Coding Alert

Question: Often, the gastroenterologist will remove several polyps via colonoscopy using the same technique. Less often, she also treats polyps with different removal methods during the same visit. Can I report multiple codes in these office situations?


Missouri Subscriber

Answer: You should report all polyp-removal codes once per session, regardless of the number of polyps the physician removes. Therefore, when the gastroenterologist performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you cannot report multiple codes.

For instance, if the physician removes and cauterizes three polyps during a colonoscopy, you should report a single unit of 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) to describe the encounter.

In contrast, if the physician ablated one polyp with an argon plasma coagulator (APC), then removed the other two by snare technique, you would:

- report 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 the APC ablation

-  report 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the polyp removals with the snare

-  attach modifier 59 (Distinct procedural service) to 45385 to show that the APC ablation and the snare removals were two distinctly different procedures.

Be sure your documentation supports the two removal methods and explains why both were necessary.