General Surgery Coding Alert

Question: I am new to coding colonoscopies. If the surgeon biopsies multiple polyps in different areas of the colon, should I report 45384 only once?

Montana Subscriber  

Answer: Yes, for biopsy only during a single colonoscopy, you should report one unit of 45380 (Colonoscopy, flexible, proximal to the splenic flexure; with biopsy, single or multiple), even if the surgeon took several biopsies from different areas. But the technique the surgeon uses does affect coding: If the surgeon used hot biopsy forceps, the appropriate code is 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). For snare technique, the appropriate code is 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Once again, only a single unit of either 45384 or 45385 is appropriate, regardless of the number of lesions removed.
 
Some insurers, including Medicare, will reimburse separately if the surgeon uses more than one technique to remove lesions. For instance, if the physician uses both snare and hot forceps to remove polyps during the same session, he or she may report both 45384 and 45385, and Medicare will apply the multiple endoscopies rule to determine reimbursement. In other words, the higher-valued procedure (45385) will be paid in full. Because both scopes include the value of a diagnostic scope (in this case, 45378), the second scope (45384) will be reimbursed at the regular rate minus the value of the diagnostic scope (because this was already paid for as part of 45385).
 
Not all payers follow this rule. Many private payers will only pay for a single scope, whether the surgeon uses multiple techniques or a single technique. Ask your payer for guidelines.   Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.