How to Code Endoscopic Biopsies with Excisions

Surgeons at our freestanding ASC occasionally take biopsies and perform excisions during gastrointestinal endoscopy. How should we bill for this?

A.

According to HCFA1 and AMA2 guidelines:

1. If the surgeon biopsies a single lesion but does not excise it, use only the biopsy code. For example, let's say a surgeon performs a colonoscopy and biopsies a sigmoid colon polyp. Use CPT code 45380, colonoscopy with biopsy.

2. If the surgeon biopsies the lesion and then excises the remainder, code only for the excision. For example, say a surgeon performs a colonoscopy with biopsy and cautery of a sigmoid colon polyp. Use 45383, colonoscopy with ablation of polyp.

3. If the surgeon takes multiple biopsies from one or more lesions, but fully excises none of them, use only the biopsy code and list it only once. For example, let's say Dr. Jones performs a colonoscopy with two biopsies of a single sigmoid colon polyp, and Dr. Smith does a colonoscopy and biopsies a sigmoid colon polyp and a transverse colon polyp. Both cases call for code 45380, colonoscopy with single or multiple biopsy.

4. If the surgeon biopsies one lesion but excises a different lesion, there are two possible courses of action.

If there is an applicable CPT code for excision that explicitly states "with or without biopsy," use it. For example, let's say that during cystoscopy, a urologist biopsies a 0.3 cm urethral polyp and fulgurates a 0.4 cm trigone bladder lesion. The correct code is 52224, cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of minor (less than 0.5 cm) lesion(s) with or without biopsy. Although the surgeon is doing two procedures on two separate lesions, there is a CPT code for removal of lesions of this size "with or without biopsy," so that code is most appropriate.

If there is no such code, use both the code for excision and the code for biopsy. To the biopsy code, append the modifier ????-???59. This modifier identifies procedures and services that are not normally reported together, but are appropriate under the circumstances.

For example, let's say a gastroenterologist does a colonoscopy with biopsy of a sigmoid colon polyp and snare removal of a transverse colon polyp. Use 45380-59 for colonoscopy with single or multiple biopsy, and 45385 for colonoscopy with snare removal of polyp.

A few notes:

• Surgeons can excise lesions in one of several ways (for example, resection and removal have separate codes). Be sure you code appropriately for the case.

• Remember that the guidelines apply to any form of endoscopic surgery, not just those performed on the gastrointestinal tract.

• When doing Medicare cases, always reference the Medicare Correct Coding Initiative (CCI) edits prior to billing. These help prevent "fragmentation," or separate coding of a procedure's components when a single code is more apropos. For more information, call your Medicare carrier or the National Technical Information Service (NTIS) at 1-800-553-6847.