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colonoscopy - The physician removes a polyp

  1. Default colonoscopy - The physician removes a polyp
    Medical Coding Books
    The physician removes a polyp from the transverse colon, then a smaller polyp at the rectum during a screening. Are both polyps coded or just one? the physician has charged for both on his pro fee and is adamant about this.

  2. #2
    Columbus, Ohio
    Was the removal techniques the same for both removals?

  3. Default
    If the doctor used the same technique on both polyps he can not bill for them separately.

    if he used a snare for the transverse and a cold bx for the rectal then he can bill for them using modifier 59 on the bx removal.

  4. #4
    If the physician removes the polyps via different methodologies, (i.e. snare, hot biopsy forceps, or cold biopsy forceps) and the polyp is in a different region of the colon, then yes absolutely!! Please see below:

    45380: colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
    1. The physician performs the colonoscopy and obtains tissue samples
    2. This code can be reported ONCE regardless of the number of biopsies taken
    3. According to CPT assistant, July 2004, this code is also to be used to describe polypectomy with cold biopsy forceps
    4. If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy of a separate lesion this code may be reported in addition with the appendage of -59 modifier.

    Hope this helps!
    Amy Pritchett,
    2017-2018 Secretary of Local Mobile AAPC Chapter
    2015-2016 President of Local Mobile AAPC Chapter

  5. #5
    Columbus, Ohio
    Thumbs up
    I concur with jamierenay different techniques = additional reporting with -59. Which is what I was attempting to find out.
    Amy I don't believe the polyp needs to be in a different region of the colon as log as the two separate techniques are used they are each individually reportable.

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