General Surgery Coding Alert

Question: When the surgeon uses a hot snare to ablate a polyp, then during the same session, uses the hot snare to remove a separate polyp, is it correct to code both 45388 and 45385?

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Answer: Yes, you should be able to report the following two codes together as long as you have documentation that the procedures addressed distinct anatomic sites:

• 45385 — Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
• 45388 — … with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).

Caution: In addition to clear documentation of separate sites, you’ll also need to report the two codes with a modifier. Because Correct Coding Initiative (CCI) lists 45385 as a column 2 code with 45388, you’ll need to append an appropriate modifier such as 59 (Distinct procedural service) to 45385 on your claim.

Sometimes your surgeon will perform a polypectomy with a hot snare, and then use the tip of the snare to ablate (fulgurate) remaining polyp tissue at that site. In those cases, you should list only 45385 and should not additionally report 45388.

Tip: Think of it this way — you should report 45388 only when your surgeon doesn’t remove a polyp at the same site in the same session. That’s true whether the surgeon uses hot biopsy forceps, snare cautery, cold biopsy forceps, or cold snare. In those cases, report only the polypectomy code that describes the method, and consider the ablation of any remaining polyp cells as a bundled service.