Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Coding & Billing
Anatomy of a GI Operative Report
Lolita Jones
Publish Date: October 10, 2007   |  Tags:   Financial Management

Lolita Jones, RHIA, CCS Operative reports are as different as the surgeons filing them. Some reports guide your coder immediately to the correct CPT(s), while others make the coder hunt for crucial information. What's more, two reports may describe basic procedure details two very different ways.

Lolita Jones, RHIA, CCS\ Meanwhile, your coder must decide whether the report justifies claiming multiple CPTs or if it indicates only one CPT. While some payers don't reimburse multiple techniques to remove multiple lesions, Medicare and many others do - provided they receive the proper medical documentation supporting the national Correct Coding Initiative (CCI) bundling edits.

As GI facilities in particular often fail to recognize these opportunities, we're presenting three GI operative reports. See if you can match the operative report's key words to the correct code(s). Use the red numbers to decode the key clues.

Patient DOB: 5/31/1925
Procedure date: 4/1/2004
Premedications: Sublimaze 75 mcg, Versed 1.75 mg IV.
Procedure indications: Colonic polyp follow-up.
Procedure: Passed scope to the cecum. Multiple diminutive polyps seen. Three removed from the transverse colon and one from the ascending colon. Two removed with snare cautery technique and two removed with hot biopsy forceps. The patient tolerated the procedure well. The remainder of the colon was unremarkable without other mass lesions or inflammatory changes. No diverticula encountered.
Impression: Multiple diminutive colonic polyps (4) - submitted to pathology.

Five Colonoscopy Techniques That May Trigger Multiple CPTs

If your surgeon uses multiple techniques on different lesions or polyps, the physician's procedure report should specifically describe the technique, the type of lesion and the location of the lesion. Here are five common colonoscopy techniques referenced in operative reports that may entitle you to claim multiple CPTs for reimbursements.

? Snare technique. Surgeons may "decapitate" small polyps, using non-electrosurgical snare devices. Most colonoscopy reports describe the use of a "snare technique." The report may also include the phrases "hot snare," "monopolar snare," "cold snare" or "bipolar snare," all of which should be reported using the appropriate CPT for the snare technique removal.

? Ablation. Surgeons perform tissue ablation (of tumors, polyps or other lesions) with devices ranging from heater probes, bipolar probes and argon lasers. It's appropriate to report these procedures regardless of whether the surgeon obtained a tissue sample with a biopsy forceps before applying the ablative device.

? Injection. In unusual cases, the procedure report may say the physician injected a polyp with saline or "lifted" it before removal by another technique. Sometimes, the surgeon may use injection to "tattoo" an area with India ink for later identification during surgery or a subsequent procedure. In both cases, it's OK to report a code for endoscopy with submucosal injection as a reimbursable service performed in addition to other reimbursable therapeutic procedures.

? Single or multiple biopsies. GI docs use the term biopsy to describe the use of a forceps to grasp and remove a small piece of tissue without applying cautery. Colonoscopy reports may describe the biopsy of a lesion or polyp using a "cold forceps" or may not mention the device. The technique is the same, and your coder should report the service CPT 45380 regardless of the final histology of the piece of tissue removed. Note that colonoscopy with removal by snare technique (code 45385) shouldn't be used for a report describing the removal of a small polyp by "biopsy" or "cold forceps" technique.

? Bleeding control. Operative reports may also describe an injection in conjunction with attempts to control spontaneous bleeding resulting from diverticulosis, angiodysplasia or prior session interventions. If so, report the procedure with a code for endoscopy with control of bleeding, rather than a code for endoscopy with submucosal injection. You may not separately report bleeding starting as the result of a therapeutic intervention (such as snare removal or biopsy) using endoscopy codes for control of bleeding or endoscopy with submucosal injection. The reason: The bleeding is considered part of the initial therapeutic procedure.

- Lolita M. Jones, RHIA, CCS

How to code Operative Report 1
One important clue for finding the correct code is the phrase "advanced to the cecum." This means the surgeon performed a colonoscopy, rather than another type of endoscopy. The report says the physician used two different techniques to remove the four distinct polyps discovered in the transverse and ascending colon. This matches to two CPTs - 45385 and 45384. Use modifier ?59 for the latter, indicating a distinct procedural service.

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

45384-59 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery.

Also, the report notes that the department of pathology analyzed the polyps the surgeon removed, so be sure to include the pathology report to support your claim.

Procedure: Total colonoscopy with hot biopsy destruction of sessile 3mm mid sigmoid colon polyp and multiple cold biopsies taken randomly throughout the colon.
Preoperative Diagnosis: Fecal incontinence. Diarrhea. Constipation.
Bowel Preparation: The bowel preparation with GoLYTELY was good.
Anesthetic: Demerol 50mg and Versed 3mg IV.
Report: The digital examination revealed no masses. The pediatric variable flexion Olympus colonoscope introduced into the rectum and advanced to the cecum. Took a picture of the appendiceal orifice and the ileocecal valve. Carefully extubated the scope. The mucosa looked normal. Took random biopsies from the ascending colon, the transverse colon, the descending colon, sigmoid colon and rectum. Found a 3 mm sessile polyp in the mid-sigmoid colon, which I ablated by hot biopsy .
Impression: Sigmoid colon polyp destroyed by hot biopsy.
Recommendation: I have asked the patient to call my office in a week to get the results of the pathology. Cold biopsies indicated by history of diarrhea.

Lolita Jones, RHIA, CC\S How to code Operative Report 2
In this case, it's easy to identify the procedure as a colonoscopy. The physician mentions total colonoscopy by name , refers to the specific colonoscope he used and describes advancing the scope to the cecum. It takes a sharper eye, though, to see that this case can be billed with multiple CPTs. While the report says the surgeon took "random biopsies" (CPT 45380) , it also says that he ablated a 3mm sessile polyp, which has a different CPT code (45383). List the ablation first as the higher-paid procedure and then the other biopsies with modifier ?59 as a distinct procedural service.

45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45380-59 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple- Distinct Procedural Service

Preoperative diagnosis: History of polyps.
Postoperative diagnosis: Polyps ascending colon, right transverse colon, and rectum.
Anesthesia: Versed 3 mg, fentanyl 100 mcg IV.
Procedure: Sixty-eight year old male patient placed in the left lateral position. Inserted scope. Visualized and photographed the ileocecal valve and the appendiceal lumen. Colon circumferentially inspected entire length. At the level of the mid ascending colon, found a small sessile polyp and removed polyp with cold biopsy forceps. No signs of bleeding. No signs of acute inflammation or diverticulosis seen in the sigmoid colon, but at the level of 10cm a small, flat lesion found and multiple biopsies taken. No other mucosal lesions seen throughout the exam. Air aspirated, the scope removed, and the procedure terminated. The patient was taken to the outpatient department in stable condition. We submitted three specimens to pathology:
1. Colon, hepatic flexure biopsy
2. Ascending colon biopsy
3. Colon biopsy at 30cm
Complications: None

How to code Operative Report 3
It may take a little longer to identify this procedure as a colonoscopy. The surgeon's report refers only to advancing a "scope," but describes circumferentially inspecting the entire length of the patient's colon, which is another way of saying he advanced the scope to the cecum.

But what about multiple CPTs? The report says the surgeon biopsied polyps in the mid-ascending colon and took multiple biopsies of a small flat lesion in the sigmoid colon. However, there's one code (CPT 45380) classifying both the cold biopsy forceps polyp removal and the multiple biopsies:

45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple.

All in a day's work
Dealing with different descriptive styles and learning the ins and outs of when to apply multiple CPT codes to multiple procedures go with the territory of coding and billing. When in doubt, use the National Correct Coding Initiative (CCI) bundling edits as your final verification to see if you're entitled to claim multiple CPTs.