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jeffrey Posted Wed 24th of January, 2018 10:20:21 AM
What circumstances would allow me to bill an E&M code on the same day that I do an endoscopic procedure?
jeffrey Posted Wed 24th of January, 2018 10:24:14 AM
What is the correct way to bill a colonoscopy in which a large polyp is removed by hot snare technique (with cautery) as well as tattooing the area of that polyp AND also removing other (smaller) polyps using a biopsy forcep AND also ablating some small rectal polyps using the tip of the cautery snare?
SuperCoder Answered Thu 25th of January, 2018 01:32:16 AM


As for your first query regarding E/M with minor procedure, kindly refer to the following link:

Next, as per the second scenario, appropriate CPTs would be as follows:

  • 45388 {Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)}
  • 45385 {Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique} with modifier 59
  • 45381 {Colonoscopy, flexible; with directed submucosal injection(s), any substance}


jeffrey Posted Thu 25th of January, 2018 09:02:16 AM
Thank you. I completely understand the answer and link referring to my first question. Regarding the second question: Don't you also bill for the multiple biopsies to remove the smaller polyps (45380)? Do you have to use any modifiers?
SuperCoder Answered Mon 29th of January, 2018 01:47:54 AM


If this is a commercial plan, then:
45380 - 59
The location in the colon is not going to directly affect your choice of cpt codes. That would directly affect your ICD-10 diagnosis codes - IF the pathology came back as adenomatous polyp versus hyperplastic polyp. The diagnosis codes for adenomatous polyps are based on their location in the colon. The hyperplastic polyp diagnosis is just one diagnosis, not based on location in the colon.
For CPT usage, you can code separately for separate instrumentation - but only once per instrument per surgical session, and with using a modifier (Typically this means -59 for commercial plans and -XU for Medicare plans. But every payer has different rules for modifier usage so you'll need to be aware of those.) AS LONG AS the instruments are not used on the same exact polyp.
For instance -
Doctor uses a snare to resect 3 different polyps = 45385 coded once (not 3 times) Your example = doctor also resects a different polyp using cold biopsy forceps = then you would also code a 45380 with a modifier.
If the doctor first attempted to resect a polyp with a snare - but then had to go back to that SAME polyp site and use biopsy forceps to resect the remainder of the polyp, you can't use both the 45385 and the 45380 because it is the same polyp.


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