You might want to review your endoscopy operative reports to make sure that your coders have been reporting submucosal GI injections. I'm sensing that many coders haven't been, either because they don't know that injection codes 43201, 43236, 45335 and 45381 are on the ASC List (they are, since 2003) or because they think they can only report these codes when an injection is the only procedure performed (not so). Here's how to make sure you're reimbursed for these longer and more difficult endoscopic procedures.

Colonoscopy coding made simple
Here are four guidelines from the January 2004 CPT Assistant newsletter coders should keep in mind when reporting these injection codes:

• If the physician used multiple techniques on different lesions or polyps, then the procedure report should specifically describe the technique, the type of lesion and the location of the lesion. The CPT code descriptors for each specific technique include language to indicate that you should report each code only once, even if multiple sites are treated with the same technique. When the physician uses different techniques on separate sites, list the code with the highest relative value first on the claim. List other codes with distinct procedural service modifier -59 to identify that the service was performed at a separate site.
• In unusual cases, the procedure report may indicate that the physician injected a polyp with saline or "lifted" it before he removed it by another technique. In other cases, injection will be performed to "tattoo" an area with India ink for later identification during a subsequent procedure or during surgery. In both of these cases, report 45381 (endoscopy with submucosal injection) as an additional service to any other therapeutic procedure.
• Reports may also describe injection in conjunction with attempts to control spontaneous bleeding resulting from causes including diverticulosis, angiodysplasia or prior session interventions. Examples include injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler and plasma coagulator. Report this procedure with an endoscopy with control of bleeding code (45382) rather than a submucosal injection code (45381).
• Bleeding that starts as a result of a therapeutic intervention (snare removal or biopsy, for example) and is controlled by any method is considered part of the initial therapeutic procedure. Don't report this separately with an endoscopy with control of bleeding code or an endoscopy with submucosal injection code.

Case study: saline lift
Follow along in this example. A patient's pre-operative diagnosis was a change in bowel habits. A colonoscopy found a 2.5cm colon polyp in the sigmoid colon and occasional diverticulum. The physician removed the polyp by submucosal saline lift and hot snare cautery. Hemostasis was achieved. Retroflexion was performed and was otherwise normal. How would you code this case?

• 45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.
• 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s) or other lesion(s) by snare technique.

Because the physician lifted the polyp with saline before he removed it with hot snare cautery, you'd report a code for endoscopy with submucosal injection as an additional service to any other therapeutic procedure. So in addition to the snare cautery removal technique, you also can code the injection procedure for this case.

You might consider designing a GI endoscopy form that lists the various procedures that your center hosts to help your physicians identify each endoscopic procedure they perform per session.

Keep in mind the code descriptor for 45335 and 45381 is generic in stating "any substance" and should be reported only once for each procedure, regardless of the number of injections performed.

Unlisted procedure code no more
Before the addition of these submucosal injection codes in 2003, there were no codes in the CPT code set that adequately described the additional time, work and risk to the patient with these more involved endoscopic procedures. Now that you can get reimbursed, don't miss out on this often-overlooked revenue opportunity.