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Biopsy by snare, ablation and EMR

Eleen Posted Thu 18th of May, 2017 09:53:47 AM
How would the following be coded: A post polypectomy scar was found in the proximal ascending colon with an adherent clip just outside the cecum at prior polypectomy site. There was residual polypoid tissue though it did not appear frankly adenomatous.=. Fulguration to ablate the remaining base of the lesion by snare was successful. Biopsies were taken with a cold forceps for histology. A 5 mm polyp was found in the proximal ascending colon. The polyp was sessile. The polyp was removed with a cold snare. Resection and retrieval were complete. A tattoo was seen in the proximal transverse colon adjacent to this a post-polypectomy scar was found with adherent clip and residual sessile polypoid tissue.. The polyp was removed with an EMR technique. The lesion was injected for submucosal lift with saline. The lesion was then resected with piecemeal hot snare with attention to clear wide margins. My thought was: 45385, 45388 and 45390. However I am getting NCCI edits about bundling. Even with modifiers appended. Thank you!
SuperCoder Answered Fri 19th of May, 2017 06:27:32 AM

Thanks for your question.


Although the provider used multiple methods for treatment, you would not be able to report two different colonoscopy methods for the same site. The appropriate coding for your scenario is 45385 for colonoscopy with the use of a snare ablation in the proximal ascending colon and 45381 for colonoscopy with saline injection in the proximal transverse colon. 45390 colonoscopy with EMR is an option for the treatment in the proximal transverse colon, but you cannot bill both 45390 and 45381 for the same site.


Hope this helps.

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