Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Let's start by looking at some information that's contained in the following op note:
In the right colon, two 6 to 7mm polyps were noted. Using snare polypectomy technique with cautery both of these polyps were removed. The colonoscope was then withdrawn into the rectum where a small, flat 1 or 2mm polyp was found and this time the polyp was ablated using cautery from the tip of the polypectomy snare.
The question is, should a coder report 45383 (ablation) in addition to 45385 (snare) for the rectal polyp that was ablated?
No, not according to the AMA which refers to information from the American Society for Gastrointestinal Endoscopy (ASGE). Ablation of small polyp(s) is not often performed as a stand-alone procedure, but commonly will occur when using a snare to remove much larger polyps. When it's not necessary to submit a tissue specimen and the same tool is used to expedite removal the physician work involved does not warrant reporting an additional CPT code. There is also the argument that this type of polyp would be amenable to removal by other techniques (biopsy forceps, hot biopsy, or bipolar cautery) so for the example listed above the only service that should be reported is 45385 – Colonoscopy with removal of tumor(s), polyps(s), or other lesion(s) by snare technique.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.