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Topic: Break the chain of common coding errors-Avoid gastroenterology coding mistakes

Ambulatory Surgery Reimbursement Update, March 18, 2008

Accurately coding colonoscopies is challenging. Coders frequently struggle to capture various techniques the physician performs on different polyps. The end result is a loss of reimbursement for the facility.

For example, when a physician performs a colonoscopy and removes several polyps, using a different removal technique for each, he or she should document, in detail, the technique used to remove each polyp, says Cristina Bentin, CCS-P, CPC-H, CMA, founder of Coding Compliance Management in Baton Rouge, LA.

American Medical Association CPT coding guidelines allow coders to report multiple polypectomies performed with multiple techniques (e.g., biopsy/cold biopsy forceps, hot biopsy forceps, ablation, snare). Physicians may not be accustomed to documenting specific techniques, and they may assume that reimbursement is the same, regardless of how many techniques they employ. However, many carriers do reimburse both the physician and the facility for multiple procedures/techniques.

"On the facility side, the coder should report multiple techniques when performed on multiple lesions," says Bentin. "For example, if the surgeon performed a colonoscopy with polyp removal by hot biopsy forceps in the descending colon (CPT code 45384), and a cold biopsy forceps removal in the transverse colon (CPT code 45380) in the same session, then coders can and should report both [techniques]. The different techniques performed on these lesions are represented by two distinct CPT codes."

Editor's note: This article is an excerpt from the April 2008 issue of Ambulatory Surgery Coding and Reimbursement Insider. For more information on how to avoid common coding mistakes at your ASC, visit www.hcpro.com/content/207097.cfm.

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