tci General Surgery Coding Alert - 2018 Issue 3

Reader Question: Check CCI for 2 Scopes

Question: Our surgeon performed a colonoscopy, removing one polyp, but he also documented a submucosal injection. Can we bill for both services? Texas Subscriber Answer: In some situations, you can collect for both services. For instance, if your physician performs a polypectomy (such as 45385, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and injects ink for tattooing for subsequent resection during the same session (45381, Colonoscopy, flexible; with directed submucosal injection(s), any substance), you can report both procedures. CCI review: Before reporting codes like this together, you should always check Correct Coding Initiative...

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