General Surgery Coding Alert

Question: Please help me code this op note: Surgeon resected and retrieved an 8 mm polyp in the descending colon by snare technique. Noting excessive bleeding, the surgeon performed argon-plasma fulguration and placed a hemostatic clip. I’ve been told we should use 45388 for the additional work to stop the bleed. How should we code the case?

California Subscriber

Answer: You should code the service as 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique).

Despite the documentation of additional work to cauterize the bleed at the site of the excision, you should not additionally report a code such as 45388 (Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).

CCI edits identify 45385 as a column 2 code for 45388 as “mutually exclusive” procedures, meaning that the surgeon would not reasonably both excise a polyp by snare technique, and also destroy (ablate) the same polyp.

Although you can override the edit pair with the appropriate modifier, such as 59 (Distinct procedural service), that is not warranted for work at the same surgical site.

If the surgeon documents considerable work beyond the time and complexity required for a typical 45385 service, you might consider appending modifier 22 (Increased procedural services).