Billing CPT 45385,45383, 45384 and multiple polyps

Don’t Become Ensnared in Polyp-Removal Codes

Choose the right code by pinning down the removal method.

If you don’t correctly code your gastroenterologist’s polyp-removals methods, you could be risking denials on your claims. But how do you choose between the codes? Look to the polyp removal technique for the answer.

Here’s how.

Use 45385 for Total Polypectomies

Gastroenterologists usually perform a total or entire polypectomy with an electrocautery snare — a heated wire loop that shaves off the polyp. When the physician uses the snare technique during a total polypectomy, you should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

For Polyp Ablation, Use 45383

Ablation usually refers to the cauterization of a polyp during a colonoscopy when the polyp cannot be removed by other techniques or during follow-up colonoscopy when your gastroenterologist discovers remnants of previously removed polyps. 

The physician uses an argon plasma coagulator, heater probe, or other device to destroy any remaining polyp cells after an earlier colonoscopy in which the physician removed a larger polyp using a snare.

When your gastroenterologist uses any of these methods for an ablation of either a non-bleeding angiodysplasia or polyp tissue from a site where tissue was not removed during the same procedure, you should report 45383 (… not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Hot Biopsy, Bipolar Cautery Forceps Require 45384

If your gastroenterologist uses bipolar forceps to both remove and cauterize a polyp simultaneously, you should report 45384 (… with removal by hot biopsy forceps or bipolar cautery). You can also apply this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps.

Multiple Polyps, 1 Technique Means 1 Code

If your gastroenterologist uses the same technique to remove both polyps, you would report it with one code.

For instance, you would report 45384 if your doctor used hot biopsy forceps to perform polyp removals at different sites at the same time.

Rule of thumb: No matter how many tumors, polyps, or lesions the doctor treats by the similar techniques, remember that the words “tumor(s), polyp(s), or other lesion(s)” in the descriptions of 45383, 45384, and 45385 signal that you’re also restricted to reporting only one of these codes per colonoscopy.

Example: A patient came in to the ambulatory surgical center (ASC) for a screening colonoscopy. The gastroenterologist found two polyps in the sigmoid colon and another two polyps in the ascending colon. She removed them all with hot forceps. Even though your gastroenterologist removed four polyps, she used the same technique for all four. Therefore, you can only report 45384 once, not four times.

Exception: When the surgeon uses different techniques, however, you can bill multiple tumor, polyp, or lesion removals, as long as you report each code only once per technique.

Two polyps, two techniques:

Your gastroenterologist used the snare technique to remove the first polyp and hot biopsy forceps to remove and control bleeding during the second polyp removal. As long as documentation supports the need for using different techniques on different polyps, you should report both 45385 and 45384.

CY 2014 CPT Code CY 2015 HCPCS Code Long Descriptor

45339 G6022 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45345 G6023 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

45383 G6024 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45387 G6025 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)

CPT Code Short Description Summary of Changes

45388 Ablation Code 45383 has been deleted. New code 45388 includes balloon dilation, guide wire insertion and ablation. Not

separately reportable with dilation code 45386 for the same lesion.

45389 Stent placement Code 45387 has been deleted. New code 45389 includes pre- and post-dilation and guide wire passage. Not

separately reportable with dilation code 45386. Use 74360 if fluoroscopic guidance is performed.

45391 Endoscopic ultrasound Now specifies exam limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. Report only once per session. Not separately reportable with EUS FNA code 45392 or radiologic ultrasound codes 76872, 76975.

COLONOSCOPY

Changes in colonoscopy guidelines section

New definition: Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. 

45355 45399 Transabdominal colonoscopy via colotomy

Code 45355 has been deleted. Report with new code for unlisted colon procedure, 45399. Code

45399 does not include moderate sedation.

45378 45378 Colonoscopy Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis.

45379 45379 Foreign body “Foreign body(s)” replaces “foreign body.” Use 76000 if fluoroscopic guidance is performed.

45380 45380 Biopsy Not separately reportable with EMR code 45390 for the same lesion.

45381 45381 Submucosal injection Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45382, 45390.

45382 45382 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45381, 45398 for same lesion.

45383 45388 Ablation Code 45383 has been deleted. New code 45388 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45386 for the same lesion.

45384 45384 Hot biopsy Bipolar cautery was deleted as an example. 

45385 45385 Snare Not separately reportable with endoscopic mucosal resection described by 45390 for the same lesion.

45386 45386 Dilation New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45388, 45389. Use 74360 if fluoroscopic guidance is performed.

45387 45389 Stent placement Code 45387 has been deleted. New code 45389 includes pre and post dilation and guide wire passage.

Not separately reportable with dilation code 45386. Use 74360 if fluoroscopic guidance is performed. 

Appendix DD: Inclusions PC 6

Brief description DD.1 (CPT) DD.2 (LOINC)

Sigmoidoscopy 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345

Barium enema 74270, 74280

Colonoscopy 44388, 44389, 44390, 44391, 44392,

44393, 44394, 44397, 45355, 45378,

45379, 45380, 45381, 45382, 45383,

45384, 45385, 45386, 45387

45378 X Flexible Colonoscopy Proximal to Splenic Flexure

45379 X Flexible Colonoscopy Proximal to Splenic Flexur...

45380 X Flexible Colonoscopy Proximal to Splenic Flexur...

45381 Colonoscopy, Flexible, Proximal to Splenic Flex...

45382 Colonoscopy, Flexible, Proximal to Splenic Flex...

45383 Flexible Colonoscopy Proximal to Splenic Flexur...

45384 Flexible Colonoscopy Proximal to Splenic Flexur...

45385 Flexible Colonoscopy Proximal to Splenic Flexur...

45386 Colonoscopy, Flexible, Proximal to Splenic Flex...

45387 Colonoscopy, Flexible, Proximal to Splenic Flex

Cholesterol screening (dyslipidemia): children at risk due to known family history, when family history is unknown, or with personal risk factors such as obesity, high blood pressure or diabetes, after age two but by age 10 (periodicity schedule/Bright Futures) Screening is covered as preventive once every 5 years ICD10: Z76.2, Z13.220 80061, 82172, 82465, 83695, 83718, 83719, 83721, 84478 Cholesterol screening (dyslipidemia  in adults: 

• Men age 35 and older: or age 20–35 if risk factors for coronary heart disease are present 

• Women age 45 and older: or age 20–45 if

risk factors for coronary heart disease are present Screening is covered as preventive once every 5 years ICD10: Z00.00, Z00.01, Z13.220 80061, 82172, 82465, 83695, 83718, 83719, 83721, 84478 Colorectal cancer screening: beginning at age 50 by any of the following ethods: 

• Fecal occult blood testing (FOBT)/fecal immunochemical test (FIT), annually

• Sigmoidoscopy every five years • Colonoscopy every 10 years • Double contrast barium enema (DCBE) ICD10: Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z12.13, Z80.0, Z83.71, Z83.79

Furthermore, we refined the total time values as follows: 238 minutes for CPT code 36831, 266 minutes for CPT code 36832, and 296 minutes for CPT code 36833.

(7) Illeoscopy, Pouchoscopy, Colonoscopy through Stoma, Flexible Sigmoidoscopy and Colonoscopy (CPT Codes 44380, 44381, 44382, 44383, 44384, 44385, 44386, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 44799, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45346, 45340, 45341, 45342, 45345, 45347, 45349, 45350, 45378, 45379, 45380, 45381, 45382, 45383, 45388, 45384, 45385, 45386, 45387, 45389, 45390, 45391, 45392, 45393, 45398, 45399, 0226T, 46601, 0227T, and 46607 and HCPCS Codes G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, G6027, G6028) 

TABLE 26: Lower Gastrointestinal Endoscopy G-Codes Replacing CY 2015 CPT Codes CY 2014 CPT Code1 CY 2015 HCPCS Code

Long Descriptor

44383 G6018 Ileoscopy,through stoma;with transendoscopic stent placement (includes predilation ) 

44393 G6019 Colonoscopy through stoma;with ablation of tumor(s),polp(s),or other lesion(s)not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

44397 G6020 Colonoscopy through stoma;with transendoscopic stent placement (includes predilation)

44799 G6021 Unlisted procedure,intestine

45339 G6022 Sigmoidoscopy, flexible; with ablation of tumor(s),polyp(s),or other lesions(s)notamenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45345 G6023 Sigmoidoscopy, flexible; with transenoscopic stent placement (includes predilation) 

45383 G6024 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45387 G6025 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)

0226T G6027 

Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when performed 0227T G6028 

Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); with biopsy(ies).

CPT Code   Description

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 (add modifier PT for Medicare or modifier 33 for commercial payers when screening was indication or finding was discovered during screening procedure)

Appendix DD: Inclusions PC 6

Brief description        DD.1 (CPT)         DD.2 (LOINC) 

Colonoscopy 

44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387

APPENDIX H: BUNDLED SURGICAL TRAY CROSSWALK

Procedure      Component Code     Procedure Code       Procedure Code Type      Effective Date       Termination Date STRY3 45384 CPT4 1/1/2007

Coding System: CPT-4

Code INACT UID Description

45378 X Flexible Colonoscopy Proximal to Splenic Flexure
45379 X Flexible Colonoscopy Proximal to Splenic Flexur...
45380 X Flexible Colonoscopy Proximal to Splenic Flexur...
45381 Colonoscopy, Flexible, Proximal to Splenic Flex...
45382 Colonoscopy, Flexible, Proximal to Splenic Flex...
45383 Flexible Colonoscopy Proximal to Splenic Flexur...
45384 Flexible Colonoscopy Proximal to Splenic Flexur...
45385 Flexible Colonoscopy Proximal to Splenic Flexur...
45386 Colonoscopy, Flexible, Proximal to Splenic Flex...
45387 Colonoscopy, Flexible, Proximal to Splenic Flex