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AHA Coding Clinic® for HCPCS - 2024 Issue 3; Ask the Editor

Application of tissue localization marker (clip) during colonoscopy

A patient with a colon mass presented for colonoscopy. After sedation, the colonoscope was introduced into the anal canal and advanced; the physician found a mass in the cecum with intussusception. The mass was pushed back reducing the colon all the way to the cecum. A clip was placed (tissue localization marker) near the tumor to allow identification of the tumor site on imaging. The scope was withdrawn with careful examination of the remaining colon. A 1 cm sessile polyp was found in the rectum. It was excised with biopsy forceps in a piecemeal fashion. The colonoscope was removed and the patient was transferred to recovery. In certain chapters of the CPT code book, codes exist for the insertion of localization markers. However, the colonoscopy section of the Digestive System chapter does not have a unique code for tissue localization marker placement. Are coding professionals to interpret the absence of a unique code to mean the clip placement is inherent to the procedure and not reported separately? Conversely, is it appropriate to report CPT code 45399 for the placement of the clip? ...

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