Monday, July 12, 2010

Billing CPT 45385,45383, 45384 and multiple polyps

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

45385* Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique


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.

Billing and Coding Guideline for CPT 45385

45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (add modifier PT for Medicare or modifier 33 for commercial payers when screening was indication or finding was discovered during screening procedure)

Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below.



Description CODE RULE CODE

45384 Incidental 45385
45384-59 Separate Reimbursement 45385

Rationale

Anthem Central Region bundles 45384 as incidental with 45385. Based on the National Correct Coding Initiative Manual, Chapter 6, it states: “If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered should be reported.” Therefore, if 45384 is submitted with 45385—only 45385 reimburses.

Anthem Central Region does not bundle 45384-59 with 45385. If one polyp is removed in one area of the intestines (45384) and another/different polyp is remove in a different part of the intestines, append modifier 59 to 45384 (45384-59) and both procedures reimburse separately.

Anthem Central Region does not bundle 45384 with 45385. Based on CPT Assistant:

“From a CPT perspective codes 45384 and 45385-51 can be reported together on the same date of service. Both codes can be reported because two separate lesions were removed by two different techniques.”

The National Correct Coding guide, does not list code 45384 as being a component to code 45385. Therefore, if 45384 is submitted with 45385—both reimburse separately.

Screening colonoscopy during which a polyp in  the large intestine is found, removed with a snare and sent to pathology. The colonoscopy procedure code: o 45385 with modifier 33 indicating that the service was preventive The screening diagnosis code: o V76.51 AND The diagnosis code for the condition found: o 211.3


Endoscopies

If multiple endoscopies are billed, special rules for multiple endoscopic proceduresapply. Medicare contractors will perform the following actions when multiple  HCPCS/CPT codes with a payment policy indicator of ‘3’ (Special rules for multiple endoscopic procedures), with the same date of service, are present:

1. Identify if the billed codes share the same Endoscopic Base Code (using the Physician Fee Schedule Payment Policy Indicator File).

2. Pay the full value of the highest valued endoscopy (if the same base is shared), plus the difference between the next highest and the base endoscopy.


Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).


Medicare contractors:

• Assume the following fee schedule amounts for these codes: 45378 - $255.40; 45380 - $285.98; 45385 - $374.56; and

• Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.

NOTE: If an endoscopic procedure with an indicator of ‘3’ (Special rules for multiple endoscopic procedures) is billed with other procedures that are not endoscopies (procedures with an indicator of ‘2’ (Standard payment adjustment rules for multiple procedures)), the standard multiple surgery rules apply .



Medicare payment guideline

In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).  Medicare contractors:

• Assume the following fee schedule amounts for these codes: 45378 - $255.40; 45380 - $285.98; 45385 - $374.56; and

• Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14. NOTE: If an endoscopic procedure with an indicator of ‘3’ (Special rules for multiple endoscopic procedures) is billed with other procedures that are not endoscopies (procedures with an indicator of ‘2’ (Standard payment adjustment rules for multiple procedures)), the standard multiple surgery rules apply.

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