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.
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.
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.
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
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.