3 Common Mistakes To Avoid When Coding Removal of Multiple Polyps Using Different Techniques

Do you find colonoscopy coding tricky? For most beginners, it can be, particularly when coding removal of multiple polyps using different techniques. You can check out below the three common mistakes coders should avoid to make colonoscopy coding easier.

First, let’s use this specific scenario as a reference for this topic.

“Op report states patient in for screening colonoscopy for malignancy and removed polyps from the ascending colon by ablation, removed two from the splenic flexure by hot probe and two from the descending colon by snare technique. Can 45388, 45384 and 45385 be reported together?”

The first mistake newbie coders often commit is the use of XS code.

#1 – Use of XS

Yes, you can code for each technique used but you do have to use a modifier for each additional code. I personally use the XU, and the reason I put that on there because someone told me they used the XS. I don’t think you’re supposed to, I think XU would be appropriate. For those of you that aren’t using XU, it’s the old -59.

#2 Missing the PT Modifier

If this is a Medicare patient being seen for the screening colonoscopy then you still have to use that PT modifier on each one of those codes, say that’s just an added thing.

CMS created the PT modifier for cases where a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure.  The PT modifier (colorectal cancer screening test, converted to diagnostic test or other procedure) is appended to the CPT® code.

#3 Failure to Identify if The Different Techniques Are Performed on The Same Polyp

One thing to watch for is that the physician is performing two different techniques on the same polyp such as using the snare and then finishing off with cold forceps. All he’s doing at that point is he didn’t get it all, so he’s going back in there with a different tool.

If he’s only trying to remove one polyp and he’s using two different techniques then we’re just going to bill for one technique because the other one was just there to help finish it off; but if he’s taking and removing polyps using different techniques anywhere up and down the colon, then, yes, you should not have any problem getting those paid as long as you’re using the appropriate modifiers.

In a nutshell, colonoscopies you can bill for any polyp removal technique as long as you have the appropriate modifiers listed.

5 thoughts on “3 Common Mistakes To Avoid When Coding Removal of Multiple Polyps Using Different Techniques”

    • You would not code for each polyp. A way to tell is if you are allowed in the code set to use an add on code. If the polyp is in the same area, same technique you can code for one.

  1. I have a questions, If a Colonoscopy w/ polypectomy in transverse colon was performed using both cold snare and cold biopsy forceps, since the cold biopsy forceps was lastly utilized for completely removing the polyp (and not the cold snare) I feel this is separately billable with mod 59, as a separate polypectomy was also performed in the sigmoid colon using hot snare technique. Two techniques were performed at two different sites for different polyps. Would proper coding be 45385 and 45380-59 in this case, or would you only code this as 45385? I remember reading somewhere that if there is the same technique performed (snare in this case) on a separate lesion that you could bill the biopsy technique (where the lesion was removed using both snare and biopsy). I could not find where I read this before unfortunately and need to have some help with clarification on this. Thanks in advance for your help!

    • As you can imagine we get quite a few medical coding, billing, auditing and risk adjustment questions on the blog each day. In order to properly allocate resources, we only answer these questions inside the CCO Community forum now. If you’re not a member, you can join for free at https://www.cco.us/cco-free-forum/

  2. would you accept respectively when a physician document: two polyps in the descending colon and rectum removed respectively by snare cautery and hot biopsy forceps .I know respectively means corresponding order but never had a physician document that way and didn’t know if insurance would accept


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