General Surgery Coding Alert

Answer: If the same technique (i.e., snare or hot biopsy forceps) was used to remove both polyps, the appropriate code should be billed only once because the procedures described include one or more polyps or other lesions.

Separate polyp removals may be billed only if different techniques were used and the polyps were located at different sites, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist in Eau Claire, Wis. For example, if the surgeon removed the polyp near the pylorus with snare, and used hot biopsy forceps to remove the fundus polyp, both services could be separately billed. Modifier -59 (distinct procedural service) would be attached to the lesser-paying code, and Medicare carriers will apply the multiple-endoscopy rule toward payment of the second procedure. If an EGD was performed (i.e., the scope went beyond the pylorus), the session should be coded as follows:

43251 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesions[s] by snare technique; 6.20 relative value units (RVUs);

43250-59 with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery; 5.40 RVUs.

The number of relative value units (RVUs) of the base code for the EGD family (43235, 4.11 RVUs) will be subtracted from the payment for the second procedure, leaving a total of 1.29 RVUs payable.

If the pyloric valve was not crossed, 43216 (esophagoscopy, rigid or flexible; with removal of tumor[s], polyp[s] or other lesions[s] by hot biopsy forceps or bipolar cautery; 4.15 RVUs) and 43217 ( with removal of tumor[s], polyp[s], or other lesion[s] by snare technique, 4.93 RVUs) should be billed. The RVUs from the base code for this family (43200, 3.06 RVUs) should be subtracted from the payment on the second procedure (leaving a total of 1.87 RVUs).