Endoscopic Mucosal Resection

Does anyone have any information of what should be documented in order to charge 45390 versus 45685 & 45381? I can't find anything of what needs to be documented. We have several physicians that do an injection to raise the polyp (45381) & does snare (45385), & they call the injection submucosal. I have done extensive research & can't find anything re: what should be documented.


  • We document the device used. For example we use the Wilson Cook Duette kit. When this is documented we bill a 45390.

    Myia Johnson, RHIA
    Business Office Manager
    Lafayette General Endoscopy Center
  • There is no NCCI edit for the code combination 45385 + 45381, in my CPT Procedures Coder's Desk Reference (2014), the definition for 45381 ends with the sentence " Submucosal saline injections, for instance, may be done before polypectomy using snare and electrocautery to greatly enhance the effectiveness of resection for large sessile colorectal polyps"

    So as long as the provider documents the injection, the reason (to lift) and the substance used, I would think that would be enough.

    DeborahAntanavica, CPC, CEMC, CGIC

    Billing Compliance Auditor III

    Department of Medicine Compliance

  • edited May 2017
    45390 was introduced in 2015 as a combination code which includes the
    injection to lift the lesion and the excision for deeper excision of lesions.
    Therefore by reporting injection and removal separately you would be
    unbundling a combination code. It may also be lifted by a cap technique or
    ligation assistance. The code includes identification and demarcation of the
    lesion, submucosal injection to lift the lesion, and endoscopic snare
    resection. The below website explains the different techniques.


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