Oncology & Hematology Coding Alert

Question: Our physician did a polyp removal from the colon. In total three polyps were removed using cauterization. In another patient, our physician documented use of hot forceps for two polyps and an APC for other lesion in the same session. We are looking for colonoscopy codes to report these polyp removals. 

Is it correct to report multiple codes in both these scenarios?

New York Subscriber

Answer: You are correct to report colonoscopy codes for the polyp removal in both the scenarios that you describe. 

However, you cannot report multiple codes for the first case where your physician removed more than one polyp using a single method in the same session. Remember, you can only report a single code for polyp removal per session irrespective of the number of polyps removed. This is the same as applies in the case of removal of stents.

Scenario1: In the first case described by you, your physician removed and cauterized three polyps during a single session. You should report only a single unit of code 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery) for the procedure. 

 Scenario 2: However, in the second case cited, your physician removed two polyps with hot forceps then ablated a lesion by an argon plasma coagulator (APC) technique presumably in a separate location. This is very different from the first scenario. In this case, you should report the following codes:

• 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for the APC ablation of the lesion.
• 45384 (…with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery) for the polyp removals with the hot forceps. 

Append the modifier: Do not forget to attach modifier 59 (Distinct procedural service) to 45384 to show that the APC ablation and the polyps removal were two distinctly different procedures on separate sites within the colon if so documented. As per the Correct Coding Initiative (CCI) edits, the CPT® code 45384 is a column 2 code for 45385 with the modifier ‘1’ that means that you can use a modifier such as 59 to differentiate the two codes.

Remember: On the claim, also be sure your documentation supports two removal methods and explains why both methods were necessary. Since you have clearly mentioned that your physician removed the two different kinds of polyps with different techniques from the colon, you can report the procedure with two CPT® codes.