# Cold forcep removal of polyp



## coderica2011

There is no specific CPT for complete removal of a polyp using cold bx forceps (during a colonoscopy). I read information in the Gastroenterology Coding Alert (Supercoder) that said to use 45385 if the polyp is  completely removed. Use 45380 if it's just biopsied.
My employer says I am to use CPT 45380 whether it's biopsied OR removed. Can anyone clarify this for me? Do you have any definitive information on this, say from Medicare?
Thank you for any help!


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## bdobyns

Code selection for polyp removal is driven by the technique used.  For example, Code 45385 specifies a techinique (Removal by Snare). As you go through the codes in the colonoscopy family nothing fits the description for a cold forcep removal. The code that best fits that description is colonoscopy with biopsy (45380).


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## bridgettemartin

By CPT definition, 45385 is removal by snare.  In the scenario you describe, 45380 would be the appropriate code.


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## coderica2011

bdobyns said:


> Code selection for polyp removal is driven by the technique used.  For example, Code 45385 specifies a techinique (Removal by Snare). As you go through the codes in the colonoscopy family nothing fits the description for a cold forcep removal. The code that best fits that description is colonoscopy with biopsy (45380).



45380 would be correct if a bx was truly being performed EXCEPT that the polyp is being completely removed. There is a big difference between a biopsy and a removal (excision)
That is why I am confused as to how to code cold bx removal (complete removal).


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## bdobyns

If cold forceps are used to completely remove a polyp it is still coded 45380.  It does not exclude a complete removal from the code, 45380 covers from a complete polyp removal to a random sample of the colon.  If the removal was not done by one of the other specified techniques  (ex. snare, hot bx) it falls under the 45380.


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## magmae

according to the AGA both a snare and a biopsy can be either hot or cold.  If the polypectomy is removed via a snare technique then use the 45385. If it is removed by 'cold forceps' then you would use the 45380.  When our reports state 'removed by cold forceps' we use 45380 since colons are coded by technique, the report has to state snare.

If they are using a snare and not stating this you may want to suggest they start so that they can get reimbursed the higher amount.


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## MikeEnos

Sorry to bring back this topic, but I came across the same question in a recent audit.

The note I'm auditing states:


> *Blah blah blah colonoscopy bit*
> Four benign appearing sessile polyps were found in the rectum. The polyps
> were 2 to 4 mm in size. These polyps were removed with a cold biopsy
> forceps. *Resection and retrieval were complete*. Two polyps were found in the
> cecum. The polyps were diminutive in size. These polyps were removed with a
> cold biopsy forceps. *Resection and retrieval were complete*.



So I came here seeking advice.  Here are the choices:
45380	 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381	 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382	 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
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
45384	 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385	 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

Since there wasn't a submucosal injection, that rules out 45381.  No control of bleeding rules out 45382.  Since the note states he used cold biopsy forceps, we can't use 45383-45385.  Seems like even though the procedure was a complete removal, the most accurate code is 45380.


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## capricew

I was leaning towards 45380 until I came across this from CPT assistant:

January 1996 page 7
Coding Consultationigestive System, 45380, 45385 (Q&A)

Digestive System, 45380, 45385 (Q&A) 

Question: How do I code a flexible colonoscopy with removal of a polyp using a cold biopsy forceps? Would this be considered the same as a hot biopsy?

Answer: The appropriate code for a colonoscopy with removal of a polyp by a cold biopsy is 45380 or 45385 depending on the actual technique employed. CPT code 45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple, should be reported for the removal of portions of the polyp by cold biopsy forceps. CPT code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, most accurately describes the removal of the entire polyp using a cold biopsy forceps. The jaws at the tip of the forceps (as opposed to a loop) surround the polyp at its stalk and severe its attachment to the colon mucosa. The polypoid lesion is then sent for pathology analysis. 


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sorry to add more confusion, but, this clearly states 45380 for a portion of polyp and 45385 for the entire polyp via cold forceps......


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## capricew

and then i found this:  45380 is the correct  code see the below more recent Cpt Assisitant:

Coding Clarification:Colonoscopy

The CPT Assistant has received a number of follow- up questions related to the article “Colonoscopy Coding Made Simple” that appeared in the January 2004 CPT Assistant. Many of the questions refer back to a Question and Answer response in CPT Assistant January 1996 that stated: “The appropriate code for a colonoscopy with removal of a polyp by a cold biopsy is 45380 or 45385 depending on the actual technique employed.... CPT code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, most accurately describes the removal of the entire polyp using a cold biopsy forceps.” 

Since the January 1996 issue, this information has been clarified. 

A forceps (or cold biopsy, cold biopsy forceps, or biopsy) is not a snare. Polypectomy does not automatically mean snare polypectomy. CPT code 45385 should not be reported for removal of polyps using forceps, as this code identifies snare technique removal. Physicians and coders should follow the instructions provided in the January 2004 issue for coding the removal of a polyp as a cold biopsy with a forceps as 45380, Colonoscopy, flexible, proximal to the splenic flexure; with biopsy, single or multiple. The term polypectomy means to remove a polyp. When used in a report, this does not define the procedure used to remove the polyp. Additional information is needed to determine the proper CPT code. Polyps of various sizes can be removed using different procedures, such as biopsy forceps, hot biopsy forceps, snare technique, and other ablation methodologies. 

Other commonly used confusing phrases in colonoscopy reports include removed in its entirety and piece-meal removal. Removing a polyp or lesion in its entirety is the subjective opinion of the surgeon at the time of the procedure. It is not relevant to selecting a CPT code for the reporting of procedures and services. Coding for the service should be based on the technique employed to resect the tissue sample(s). Some polyps are removed in pieces if a single application of the technique (biopsy forceps, cautery biopsy, or snare) is inadequate. Codes 45380, 45384, and 45385 define different techniques and can be used only once for a single colonoscopy procedure regardless of whether the technique is employed on multiple polyps or multiple times on a single polyp. 

When reading any information presented in the CPT Assistant, it is critical to keep in mind that coding is an ever evolving practice, and that any of the information in the CPT Assistant is subject to change. To be sure you have current information, you should always refer to the most recent issues for the latest in coding interpretation. 


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## acf7575

So, the provider states... "Procedure(s) Description: Under satisfactory anesthesia and full monitoring, the rectal exam was done. The colonoscope was introduced per rectally and passed through the rectum and the rectorsigmoid and descending and transverse and the ascending colon all the way to the cecum. The scope was then brought back around very slowly and carefully studying the mucosa in detail and seeing it very well.  As we came back when we removed these polyps as we came to them.  *They were all removed with biopsy forceps and cauterized except 1 in the transverse colon which was simply cauterized away. * There was a polyp in the right colon and 1 in the hepatic flexure  And 2 in  the transverse colon and one 70 cm above the anus at about the splenic flexure. At the end of the case the air was removed and the scope was removed and the procedure was terminated."
Is this 45380 of 45384? Or both since one was indicated as simply cauterized away and the others were removed with biopsy forceps then cauterized...


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## such78

acf7575 said:


> So, the provider states... "Procedure(s) Description: Under satisfactory anesthesia and full monitoring, the rectal exam was done. The colonoscope was introduced per rectally and passed through the rectum and the rectorsigmoid and descending and transverse and the ascending colon all the way to the cecum. The scope was then brought back around very slowly and carefully studying the mucosa in detail and seeing it very well.  As we came back when we removed these polyps as we came to them.  *They were all removed with biopsy forceps and cauterized except 1 in the transverse colon which was simply cauterized away. * There was a polyp in the right colon and 1 in the hepatic flexure  And 2 in  the transverse colon and one 70 cm above the anus at about the splenic flexure. At the end of the case the air was removed and the scope was removed and the procedure was terminated."
> Is this 45380 of 45384? Or both since one was indicated as simply cauterized away and the others were removed with biopsy forceps then cauterized...



45380 for forceps biopsy, cautery sounds like snare technique to me (45385), or query the surgeon to specify the cautery. If snare, I would like to assign 2 codes for this case since they are 2 different techniques in 2 different areas.


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## acf7575

suchang78 said:


> 45380 for forceps biopsy, cautery sounds like snare technique to me (45385), or query the surgeon to specify the cautery. If snare, I would like to assign 2 codes for this case since they are 2 different techniques in 2 different areas.


I queried the provider.  He stated he uses the cold forceps to biopsy then cauterizes the base as the cautery destroys to much tissue and there would not be enough for pathology evaluation.  So, is it 45380 of 45384?  He's not using a snare.  A polypectomy *snare* is a wire loop device used during *colonoscopy* designed to slip over a polyp and, on closure, results in cutting the polyp off at its stalk. Conventional *snare* polypectomy uses cautery, a hot wire with electrical current that cauterizes the tissue while removing the polyp.


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## such78

acf7575 said:


> I queried the provider.  He stated he uses the cold forceps to biopsy then cauterizes the base as the cautery destroys to much tissue and there would not be enough for pathology evaluation.  So, is it 45380 of 45384?  He's not using a snare.  A polypectomy *snare* is a wire loop device used during designed to slip over a polyp and, on closure, results in cutting the polyp off at its stalk. Conventional *snare* polypectomy uses cautery, a hot wire with electrical current that cauterizes the tissue while removing the polyp.




I would code it as 45380 after queried the doctor.


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## MarDee

I code for ASC and we always use 45385 for snare and 45380 for cold bx. Add -59 on the 45380 if both procedures are done at the same time.


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