Can 45385 and 45380 Be Billed Together?

Accurate medical coding and billing are integral to the financial operations of healthcare providers. The submission of claims to payers requires precision, as even slight errors can lead to claim denials, delayed payments, or compliance issues. Understanding how to correctly combine Current Procedural Technology (CPT) codes for procedures performed during the same encounter, and navigating the rules for billing multiple services, is a frequent challenge in healthcare administration.

Understanding CPT Codes 45385 and 45380

CPT code 45385 describes a flexible colonoscopy with the removal of tumor(s), polyp(s), or other lesion(s) by snare technique. This procedure involves using a colonoscope to examine the colon and remove identified abnormal growths. It is typically employed when a diagnostic colonoscopy transitions into a therapeutic intervention to excise detected lesions.

Conversely, CPT code 45380 pertains to a flexible colonoscopy with biopsy. This procedure involves the collection of tissue samples from suspicious areas within the colon for further pathological analysis. A 45380 procedure is diagnostic, identifying conditions such as inflammatory bowel disease, colorectal cancer, or the nature of polyps. While both codes involve a colonoscopy, 45385 focuses on removal, and 45380 is specifically for obtaining tissue for examination.

National Correct Coding Initiative (NCCI) Edits

The National Correct Coding Initiative (NCCI) is a program developed by the Centers for Medicare and Medicaid Services (CMS) to promote accurate coding and prevent improper payments. Its purpose is to ensure correct billing of healthcare services by identifying code combinations that should not ordinarily be reported together. These edits are implemented by payers, particularly Medicare, to ensure compliance with national coding methodologies.

A significant aspect of NCCI is the Procedure-to-Procedure (PTP) edits, which identify code pairs that are mutually exclusive or components of a more comprehensive procedure. When a PTP edit exists for two codes, one code is designated as “Column 1” and the other as “Column 2.” If both are submitted for the same patient on the same date of service, Medicare will typically pay for the Column 1 code and deny the Column 2 code.

For CPT codes 45385 and 45380, an NCCI PTP edit is in place. CPT code 45385 (snare removal) is the more comprehensive service, making it the Column 1 code, while 45380 (biopsy) is the Column 2 code. This means that if a biopsy is taken from a lesion and that lesion is removed by snare during the same session, only the removal (45385) should be reported. Billing both codes together without specific justification and an appropriate modifier would likely result in a denial for the 45380 service.

Appropriate Modifier Usage for Separate Procedures

When two procedures are performed on the same day but are distinct, specific modifiers can be appended to the claim. Modifier 59, “Distinct Procedural Service,” indicates a procedure or service was separate or independent from other non-Evaluation and Management (E/M) services performed on the same day. Its application requires documentation to support a different session, procedure, site or organ system, incision, lesion, or injury. Modifier 59 should only be used if no other, more specific modifier is available to describe the distinct service.

CMS has introduced more specific X-modifiers (XE, XS, XP, XU) for greater clarity than Modifier 59 alone. These modifiers function as subsets of Modifier 59:
Modifier XE, “Separate Encounter,” signifies a service distinct due to a separate encounter on the same date.
Modifier XS, “Separate Structure,” indicates a service distinct due to performance on a separate organ or structure.
Modifier XP, “Separate Practitioner,” denotes a service distinct due to performance by a different practitioner.
Modifier XU, “Unusual Non-Overlapping Service,” is for a service distinct because it does not overlap usual components.

Modifiers are relevant when the biopsy (45380) and the snare removal (45385) are performed on separate lesions during the same colonoscopy. In this scenario, Modifier 59 or the more specific Modifier XS can be appended to CPT code 45380 to indicate the biopsy was on a distinct lesion from the one removed by snare. If these procedures occurred during separate encounters on the same day, Modifier XE would be appropriate. The modifier should always be appended to the Column 2 code (45380) in the NCCI edit pair.

Documentation and Reimbursement Considerations

Comprehensive and precise medical record documentation is important when billing CPT codes with modifiers. The documentation must clearly substantiate the reason for using a modifier, proving the services were distinct and not components of a single, more extensive procedure. This includes detailing the medical necessity for each separate procedure and outlining how they meet the criteria for distinctness.

For colonoscopy procedures involving both biopsy and snare removal, the medical record should clearly identify the location and nature of each lesion. Specify if the biopsy was taken from a lesion different from the one removed by snare, or if procedures occurred at different colon segments. Without detailed documentation, claims with modifiers may face scrutiny, leading to denials, appeals, or post-payment audits and recoupments. Payers, including Medicare, review claims with modifiers to ensure appropriate use and compliance.

Reimbursement for bundled services covers the most comprehensive procedure, but when services are appropriately unbundled with modifiers and supported by documentation, separate payment may be possible. However, even with correct coding and robust documentation, some claims might be denied and require appeal. Maintaining meticulous records supporting the distinct nature of each service is necessary for maximizing reimbursement and avoiding financial setbacks.