Outpatient Facility Coding Alert

Published on Thu Mar 20, 2014 PDF

Question: A colonoscopy was done in August 2013 on a patient with snare removal of a polyp. The same patient returned in February 2014 for another colonoscopy to remove a polyp which was incompletely removed during the first procedure. How would I code this? Should I use modifier 76?

Wyoming Subscriber

Answer: For removal of tumors, polyps, or other lesions by various techniques, you can use codes 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) and 45385 (… with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Along with the appropriate code use reduced service modifier 52 (Reduced services) to indicate the subsequent partial removal. Location of removal is also important should additional polyps be found.