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Thread: terminal ileum polyps removed

  1. #1

    Wink terminal ileum polyps removed

    AAPC: Back to School
    Dr. removed polyps at terminal ileum along with ployps from colon, is this still 45385 only. Need modifier 22 or 59?

  2. #2
    Join Date
    Apr 2007


    for colonoscopies you can code "per technique" therefore you would use a 59 modifier on the 2nd technique.
    Last edited by mbort; 07-24-2008 at 09:11 AM. Reason: correction

  3. #3


    Quote Originally Posted by mbort View Post
    for colonoscopies you can code "per site" therefore you would use a 59 modifier on the 2nd site.

    For Colonoscopies . its not the site but the techinique used for removal of polyp is to be considered. If multiple polyps are found in different parts of colon and rectum and snare technique has been used for the removal, then only once 45385 is reportable. See this CPT assistant article for more clarification.

    Colonoscopy with Biopsy of Polyp with Hot Biopsy Forceps
    CPT Assistant, Special Issue 2005, page 4


    If a physician performs a colonoscopy and biopsies a polyp with the hot biopsy forceps (without entirely removing the polyp), what CPT code should be reported?
    Does the fact that this biopsy was performed using hot biopsy technique qualify for reporting code 45384?
    -Barbara L. Bunge, RHIA, CCS, CCS-P Iowa

    AMA Comment:

    From a CPT coding perspective, CPT 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, should be reported. Coding for the service should be based on the technique employed to resect the tissue sample(s). Codes 45380, 45384, and 45385 define different techniques and can be used only once for a single colonoscopy procedure regardless of whether the technique is employed on multiple polyps or multiple times on a single polyp.

    Hope this benefit all of us.

    Thank You
    Amit Joshi MSc,CPC,CPC-H

  4. #4
    Join Date
    Apr 2007


    59 will bw applicable only if the method is different for removal in this case both the polyps were removed with snare, therefore only 45385 will be reported once.


    hope this helps.

    Dr. Mohd. Ali Hadi CPC, CPC-H
    Mohd Ali Hadi- CPC-H

  5. #5

    Default Unknown technique

    I have a doubt. If the technique is not mentioned by the physician whether snare or hot biopsy, should we need to query the physician or consider 45380 as default. Please reply.

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