The question is, should a coder report 45383 (ablation) in addition to 45385 (snare) for the rectal polyp that was ablated?
No, not according to the AMA which refers to information from the American Society for Gastrointestinal Endoscopy (ASGE). Ablation of small polyp(s) is not often performed as a stand-alone procedure, but commonly will occur when using a snare to remove much larger polyps. When it’s not necessary to submit a tissue specimen and the same tool is used to expedite removal the physician work involved does not warrant reporting an additional CPT code. There is also the argument that this type of polyp would be amenable to removal by other techniques (biopsy forceps, hot biopsy, or bipolar cautery) so for the example listed above the only service that should be reported is 45385 – Colonoscopy with removal of tumor(s), polyps(s), or other lesion(s) by snare technique.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
