Heidi Posted Wed 22nd of August, 2018 10:14:57 AM
if a physician indicates the polyp was removed with a lift and cut technique using snare would you bill a 45390 or 45385 since it does not say they injected lift per guidelines
When the patient is appropriately prepped and anesthetized, the provider inserts a flexible colonoscope to examine the colon for any lesion or lesions. After the identification of the lesion, she typically administers a submucosal injection to raise the lesion, making it easier to resect, or excise, it via snare or other means. Sometimes, the provider may repeat the injection in cases of deep lesions. After the excision of the lesion, she ensures hemostasis and removes the colonoscope.
SuperCoder Answered Thu 23rd of August, 2018 06:59:59 AM
Thank you for the question.
As per the provided documentation, to report CPT® code 45390, the provider administers a submucosal injection to raise the lesion, making it easier to resect via snare or other means. This CPT® code includes both the submucosal injection and snare technique.
But, the above statement indicates that nothing was injected for the lift; therefore, you are advised to report CPT® code 45385 as there was no injection utilized to raise the lesion.
If the polyp was removed with a lift and cut technique using snare, then report CPT® code 45390. Example: In lift and cut technique, the submucosal injection is performed to raise the lesion. After the injection, the grasping forceps or a snare is used to grasp and lift the lesion. Post grasping and lifting, the second snare is passed through the endoscope and the lesion/polyp is resected.
Note: Check your detailed procedure note for the method/technique utilized for the removal of the polyp.
Hope it helps.
Heidi Posted Mon 27th of August, 2018 10:18:18 AM
so even though it says LIFT AND CUT TECHNIQUE USING SNARE by your example it must say (SUBMUCOSAL INJECTION ) to classify as EMR . in any circumstances can they just lift the polyps with snare without injection?
SuperCoder Answered Tue 28th of August, 2018 03:05:42 AM
To classify the technique as Endoscopic mucosal resection, submucosal injection is mandatory.
In Endoscopic mucosal resection the polyp is lifted from the underlying tissue after administering the fluid injection (submucosal) before resecting the polyp. This fluid injection (submucosal) is often made of saline, the fluid (saline) is injected deep in the lesion and the polyp is removed in one piece. Therefore, the submucosal injection is mandatory to perform this technique.
Whereas, in other technique, where fluid injection is not administered to raise the lesion, there are two variations: These variations require a double channel endoscope.
Variation-1) The first snare is used to grasp and lift the polyp/lesion while the second snare is passed down to the base of the polyp and is resected.
Variation-2) The grasping and lifting technique is performed by utilizing the grasping forceps instead of endoscopic snare. This technique is helpful for the lesions/polyp that are slightly elevated.
Now, in your case, since there was no fluid administration performed and the polyp was removed with lift and cut technique utilizing snare, you may kindly report the procedure with CPT® code 45385.
Hope it helps.