General Surgery Coding Alert

Question:, Our carrier has told us to file colonoscopy code 45384 (colonoscopy, with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) and 45385 (coloscopy, with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) without modifiers. These two procedures are done at the same time, one using snare removal and the other hot biopsy removal of lesions. We also were told to reduce the second procedure by the base price and charge the difference. Having done so, the carrier still isnt paying us for the second procedure. How do we get paid?

Anonymous coder, Princeton, KY

Answer: Medicare has specific guidelines governing the use of these two codes based on the multiple endoscopy policy effective March 1, 1994, that is still in effect, says Kathleen Mueller, RN, CPC, CCS-P. You should bill 45385 and 45384 with modifier -59 (distinct procedural service) to indicate a separate procedure was performed on a separate site of the colon. These procedures are within the same family of endoscopy. Mueller adds that the second procedure should never be reduced unless the physician is not participating with Medicare.

Payment is based on 100 percent of the Medicare-approved amount for the 45385 as well as the difference between 45384 and 45378. You never report 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimens[s] by brushing or washing, with or without colon decompression [separate procedure]) because the diagnostic colonoscopy is always a part of the surgical colonoscopy and that is what they base the payment of the second procedure on.

Mueller also notes that since 1994, Medicare has not required that modifier -51 (multiple procedures) be attached to these services. The rule of thumb is that when multiple endoscopies with different techniques are performed on different sites, they can be reported separately. However, when multiple endoscopies using the same technique are done, they cannot. For example, a colonoscopy that involves the removal of three polyps by snare can be coded only as 45385.