tci General Surgery Coding Alert - 2022 Issue Q2

Reader Questions: See if Separate Lesion Allows Separate Code

Question: During a screening colonoscopy, the surgeon biopsied a suspicious area in the descending colon, and removed a polyp using hot biopsy forceps in the transverse colon. Can we separately code the procedures? Ohio Subscriber Answer: Yes, with the documentation of distinct anatomic sites, you can bill both 45380 (Colonoscopy, flexible; with biopsy, single or multiple) and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps). Because the National Correct Coding Initiative (NCCI) bundles 45380 into 45384, you’ll need to use an appropriate modifier to override the edit pair. For instance, you...

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