The Colorectal Cancer Control Program (CRCCP) of the Centers for Medicare and Medicaid has increased colorectal (colon) cancer screening rates among men and women aged 50 years and older. This has resulted in an increase in the number of polyps detected. Polyps are removed using various techniques, and reimbursement depends on the polyp removal method. Medical billing and coding companies work with gastroenterology practices to report and obtain fair and reasonable reimbursement for such procedures and tests. They assign the correct CPT codes depending on the technique that the gastroenterologist uses for polyp removal, which is crucial for optimizing revenue and preventing claim denial.
CPT Codes based on Polyp Removal Technique
CPT 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
The snare technique is usually used to perform a polypectomy during a colonoscopy. The snare cautery technique involves placing a wire loop around the desired piece of tissue or polyp and heating it to shave off the lesion. While larger lesions may be removed with a single application of the snare or removed using a “piecemeal” technique and remnants of the lesion cauterized or ablated, only one technique should be reported for the removal of a unique polyp or lesion.
Code 45385 should be reported regardless of whether the snare technique used is “hot snare,” “monopolar snare,” “cold snare,” or “bipolar snare”.
CPT 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
Code 45384 applies when the tumor, polyp or lesion is removed using bipolar cautery and monopolary cautery forceps. In hot biopsy forceps or monopolar cautery forceps, heat is created in the metal portion of the forceps cup by causing current to flow from the device to a grounding pad on the patient’s body to cauterize the lesion or polyp. In the bipolar cautery technique, current that runs from one portion of the tip of the cautery device to another cauterizes and removes a lesion or polyp. Any remnants of the lesion following the use of the cautery forceps can be destroyed completely via cauterization or ablation.
CPT 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). This code is not separately reportable with dilation code 45386 for the same lesion.
Colonoscopy through Stoma with Removal of Polyp
CPT defines colonoscopy through stoma as the examination of the colon, from the colostomy stoma to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. For colonoscopy through stoma with removal of tumor, polyp or other lesion, the relevant CPT codes to use are as follows:
CPT 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or
other lesion(s) by hot biopsy forceps
CPT 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
CPT 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
Modifier 33 (preventative service) should be appended if the procedure is a screening exam. This applies to therapeutic colonoscopies such as 45385 (colonoscopy, with removal of tumor, polyp, or other lesion by snare technique). Use of this modifier and the proper diagnostic codes informs payers that the diagnostic procedure is done for screening and should be reimbursed without regard to patient copayment or deductible.
The Bulletin of the American College of Surgeons dated May 1, 2016 provides the following example of reporting colonoscopy with polyp removal:
A 50-year old patient (without family or personal history) has a screening colonoscopy in which three polyps are found: a 10 mm polyp is removed from the cecum using snare technique after injection of saline to “lift” the polyp, a 5 mm polyp is removed from the descending colon by cold biopsy forceps, and a 5 mm polyp is removed from the rectum by cold biopsy forceps. A certified registered nurse anesthetist (CRNA) provides moderate sedation for the procedure.
Diagnosis — ICD-10 Codes
Use ICD 10 code Z12.11 to report: Encounter for screening for malignant neoplasm of the colon, and the following billable ICD-10 codes:
- D12.0: Benign neoplasm of the cecum
- D12.4: Benign neoplasm of the descending colon
- D12.8: Benign neoplasm of the rectum
Procedures — CPT Codes with appropriate modifiers: 33, 59 and 51
- 45385–33: Colonoscopy with snare polypectomy; modifier to indicate preventative screening procedure.
- 45380–59: Colonoscopy with biopsy, single or multiple; modifier to indicate distinct procedures. Note: report only once, even if multiple polyps are removed by the same technique.
- 45381–51: Colonoscopy with submucosal injection (any substance); modifier to indicate multiple procedures at the same setting.
- The CRNA reports 99149–33: Moderate sedation services, provided by a physician other than the physician performing the diagnostic service; modifier to indicate preventative screening procedure.
Gastroenterology medical billing and coding companies can help physicians report colonoscopy procedures to maximize reimbursement. There are major changes to endoscopy in the 2017 Outpatient Prospective Payment System (OPPS) in 2017. A reliable medical coding service provider will help physicians deal with these changes as well as the changes in the ICD-10-CM and CPT coding systems.