tci General Surgery Coding Alert - 2019 Issue Q4

Reader Question: Check Payers for Polypectomy Bundling Rules

Question: Our surgeon performed a colonoscopy and a hot-forceps polyp excision. The op note describes how the surgeon first injected saline into the mucosa under the polyp to “lift” the polyp before performing the polypectomy. Can I separately report the injection? Maine Subscriber Answer: Some payers may pay for both procedures, which you would report as 45381 (Colonoscopy, flexible; with directed submucosal injection(s), any substance) for the injection, and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps) for the hot-forceps polypectomy.  Medicare’s National Correct Coding Initiative (NCCI) edits do...

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