Ablation and Injection Coding

[ENDOCODER]

I hope someone can help with this! We are having a discussion with our doc about coding for these procedures. The report states as follow:

A single flat 15 mm non-bleeding polyp of malignant appearance was found in the rectum. 5 ml epinephrine 1/1000 inj was successfully applied for hemostatis. 20ml hypertonic salne solution injection successfully applied for saline pillow. a piece meal polypectomy was performed using a hot snare in the rectum. the polyp was completely removed. a thermal therapy device was successfully applied for polyp ablation in the rectum. Ablation applied using soft coag current at 80 watts

Can we bill 45388, 45381, and 45385? Everything was done in the rectum.

Appreciate any thoughts on this.

 

[afalcon@dhcla.com]

use 45390

 

[ENDOCODER]

Thanks for responding. I can see using 45390 for the saline injection to raise the polyp and the removal, what about the ablation that was done? Can we bill for that?

 

[afalcon@dhcla.com]

my understanding is when you perform an EMR you are typically lifting a polyp with saline and removing the tissue or polyp.
Most dr's will abalate this area to prevent bleeding or to remove any additional tissue that may have been too small to remove.

I would use only 45390

 

[ENDOCODER]

OK Thx, Appreciate your thoughts on this. My doc will not be too happy.