# polypectomy (?)



## LTibbetts (Aug 7, 2009)

Anyone want to take a shot at this? I was a bit thrown off by all of the "attempts".  

In the patients recent history he had what was though to be a benign fold in the cecum but biopsies confirmed that it was an adenomatous polyp, and it had not been completely resected.

"Procedure Findings:  In the cecum, again a fold was noted that was thought t be benign, but because of this prior experience, it was biopsied and cauterized in a manner to destroy the area of possible adenomatous change. In the proximal right colon, a 12-mm sessile polyp on a fold was present which again was very difficult to remove. A combination of snare and hot biopsy forceps polypectomies with submucosal injection, the entire polyp was either removed or cauterized with a high probability but not absolute certainty of removal of the entire polyp. No other abnormalty was found....."

I know that I can code the 45383 from the first polyp. The second one is what gets me. There were 3 different types of attempts and the doc isn't even sure if he got it all or not. I can't code for it, right?

Any input?


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## KimmHall (Aug 7, 2009)

Leslie,
  As far as I know because he was working on the same polyp then no. I have seen that happen where the patient has to have several procedures just to eridicate one very large polyp.  I would be more inclined to use the 45385 since he is unsure of whether or not he removed it all and he used both the snare and hot biopsy techniques. Depending on the carrier however you may still be able to bill for the injection(45381) with a 59 modifier but again it depends on the carrier. The 45383 code is for ablation that cant be done by hot biopsy or snare, such as APC. Just my opinion. I hope it helps. Have a great day.


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## LTibbetts (Aug 7, 2009)

I did end up going with the just the 45385 for the second polyp but going back to the first one that was removed....since he first biopsied and then ablated, couldn't I still use the 45383 for that? (ie 45385, 45383-59)


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## Anna Weaver (Aug 7, 2009)

*polypectomy*

I would use 45385, 45383-59, 45381-59 for all 3 procedures. Here's what CPT assistant has to say, it discusses submucosal injections in the second to the last paragraph. 

  	Colonoscopy with lesion removal 
	CPT Assistant, January 2004 Pages: 5-7   Category: Coding Communication
	Related Information
Lesion Removal Technique

Descriptions of the different techniques represented in the lesion removal codes should be documented when trying to identify the technique described by the colonoscopist in the operative report.

The lesion or tissue removal technique easiest to identify in the operative report is the snare technique, represented by code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. (See Figure 1) The snare technique is most often used to perform a polypectomy during a colonoscopy. When the snare cautery technique is employed, a wire loop is placed around the desired piece of tissue or polyp and is heated to shave off the lesion. Larger lesions may be removed with a single application of the snare or can be removed with several applications of the snare in pieces frequently described as "piecemeal." Remnants of the lesion after use of a snare can be cauterized or ablated to completely destroy the intended target but only one technique should be reported to remove a unique polyp or lesion.

Snare devices may also be used without electrocautery to "decapitate" small polyps. Most often the colonoscopy report will specify that a "snare technique" was used. But do not let alternative terminology throw you off. The report may also include the phrase "hot snare," "monopolar snare," "cold snare," or "bipolar snare," all of which should be reported using code 45385.

When a colonoscopist documents the use of hot biopsy forceps to remove a lesion, code 45384, Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery, is used to accurately report the service. Bipolar cautery and monopolar cautery forceps can be used to perform this service. Monopolar cautery forceps create heat in the metal portion of the forceps cup by causing current to flow from the device through the patient to a grounding pad. Bipolar cautery uses current that runs from one portion of the tip of the forceps device to another portion of the forceps device to heat the metal used to cauterize and remove a lesion or polyp. Again, remnants of the lesion after use of a cautery forceps can be cauterized or ablated to completely destroy the intended target.

Unfortunately, unlike the terminology used to describe the techniques represented in codes 45385 and 45384, the terminology used in the procedure report to indicate when code 45383, Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique, should be reported is not as clear. The definition of 45383 can be misleading because it only states what techniques the codes should not be used for: hot biopsy forceps (45384), bipolar cautery (45384), and snare (45385). It may not be possible to remove a lesion using one of these techniques and the lesion may or may not be biopsied before it is ablated using an alternative technique. In other cases, it may not be possible or necessary to obtain a tissue sample of a lesion or polyp depending upon the location. The ablation of the tissue (tumor, polyp, or other lesion) can be performed with many different types of devices (heater probe, bipolar cautery probe, argon laser, etc) regardless of whether a sample was obtained with a biopsy forceps before the ablative device is applied. Code 45383 is also frequently used to describe the treatment of benign vascular lesions.

In unusual cases the procedure report may indicate that a polyp was injected with saline or "lifted" prior to removal by another technique. In other cases, injection will be performed to "tattoo" an area with India ink for later identification during a subsequent procedure or during surgery. In both of these cases, CPT code 45381, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance, should be reported as an additional service to any other therapeutic procedure. However, reports may also describe injection in conjunction with attempts to control spontaneous bleeding resulting from causes including diverticulosis, angiodysplasia, or prior session interventions. The procedure is then correctly reported with 45382, Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator), rather than 45381. Bleeding that starts as a result of a therapeutic intervention (eg, snare removal, biopsy, etc) and is controlled by any method is considered part of the initial therapeutic procedure and should not be reported separately with codes 45382 or 45381.

CPT code 45380, Colonoscopy, flexible, proximal to splenic flexure;  with biopsy, single or multiple, does not describe a specific technique. The terminology is accepted and understood by colonoscopists to mean the use of a forceps to grasp and remove a small piece of tissue without the application of cautery. (See Figure 2)  Colonoscopy reports may describe the biopsy of a lesion or polyp using a cold forceps or may describe the biopsy without mentioning the specific device. The biopsy may be from an obvious lesion that is too large to remove, from a suspicious area of abnormal mucosa, or from a lesion or polyp so small that it can be completely removed during the performance of the biopsy, which is often demonstrated with the cold biopsy forceps technique. The technique is the same and the service is reported with code 45380 regardless of the final histology of the piece of tissue obtained for analysis. Colonoscopy with removal by snare technique, 45385, should not be used for a report describing the removal of a small polyp by "biopsy" or "cold forceps" technique.




CPT Assistant © Copyright 1990–2009 American Medical Association. All Rights Reserved 

Hope this helps.


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