Bill Posted Wed 18th of December, 2013 11:51:25 AM
I code for an ASC and I often see where a colonoscopy is performed and the pt has multiple polyps or other conditions. The surgeon removes some polyps via snare and some via biopsy forceps. Can I code "45385" and "45380-59"? Or sometimes he removes the polyp via snare but also does random biopsies to rule out some other condition. Can I code both if done during the same session? Thank you
SuperCoder Answered Wed 18th of December, 2013 14:36:07 PM
Yes both as you said in both the cases mentioned.
Code the procedure using the following:
45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for colonoscopy with removal or polyps using snare technique;
CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to describe colonoscopy with biopsy;
Modifier 59 (Distinct procedural service) attached to 45380 to indicate that it is a different procedure not ordinarily encountered or performed on the same day.
Bill Posted Wed 18th of December, 2013 16:49:09 PM
SuperCoder Answered Wed 18th of December, 2013 17:59:51 PM