Gastroenterology Coding Alert

Use biopsy codes for polypectomy in case of cold forceps.

You are looking at a loss of hard-earned dollars and a possible audit if you fail to capture the right code for your gastroenterologist’s colonic polyp removal method. Accurate assignment of polypectomy procedure codes depends on the technique used to perform the procedure, the type of scope, and the polyp location. Follow these tips to come out clean on your polypectomy coding.

What Happens During a Polypectomy

Mucosal polyps are commonly discovered during endoscopic evaluation of the GI tract. Adenomatous polyps are at risk for progression to carcinoma, hence their identification and removal is a primary goal of endoscopy. Polyps come in a wide variety of shapes and sizes, and may be present in challenging locations for removal.

The physician’s aim for a polypectomy is to representatively sample the lesion and safely remove or ablate the polyp. He may do it while examining the colon either by sigmoidoscopy, proctosigmoidoscopy, or colonoscopy. Sampling can be performed by prior cold biopsy, concurrent biopsy and ablation, or by retrieval of tissue after excision. “Polyp removal can be accomplished via hot biopsy, snare cautery, cold mechanical removal with cold biopsy or cold snare, with or without injection, or sometimes with concurrent application of electrocautery for ablation and hemostasis,” informs Michael Weinstein, MD, Vice President of Capital Digestive Care.

The gastroenterologist may frequently encounter multiple polyps requiring different removal techniques. In such a case, you must verify the location of each polyp on the colon and the type of technique needed for the removal of each lesion.

Hot Biopsy Forceps Mean Better Results

Polypectomy with hot biopsy forceps theoretically provides improved hemostasis and more complete ablation of the neoplastic tissue but may also increase the risk of delayed perforation. The physician can use either a monopolar hot biopsy forceps or a bipolar cautery forceps. If the gastroenterologist both removes and cauterizes a polyp simultaneously using hot forceps, depending on the type of scope, you can use codes:

• 44392 -- Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

• 45333 -- Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy

• 45384 -- Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.

If the physician removes a single polyp during a proctosigmoidoscopy, you can use:

• 45308 -- Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery.

Use of Snare Means Total Polypectomy

Physicians typically perform polyp removals with an electrocautery snare (a heated wire loop that shaves off the polyp). When the gastroenterologist uses snare technique during a total polypectomy, you can report:

• 44394 -- Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 

• 45338 -- Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 

• 45385 -- Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

If the physician removes a single polyp with snare during a proctosigmoidoscopy,
you report:

• 45309 -- Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique.

Always Seek Biopsy Code for Cold Forceps

Sometimes your gastroenterologist may use cold forceps to remove a polyp completely or for a partial polypectomy. Cold biopsy forceps are disposable forceps that the physician uses to take tissue samples during an endoscopy. No electric current passes through them -- thus the term ‘cold.’ You cannot use these forceps to cauterize bleeding that the forceps may cause.

When the gastroenterologist takes tissue samples with cold biopsy forceps, you should resort to biopsy code 45380 (Colonoscopy, flexible, with biopsy, single or multiple). This code will also apply for removal of small polyp using the cold biopsy forceps.

Use Ablation Codes for Destruction of Polyps

Sometimes your physician may need to destroy remaining polyp cells, which a prior colonoscopy for removal of a larger polyp (using a snare) has left undestroyed. In such a case, look out for ablation codes, depending on the cauterization technique the physician uses -- argon plasma coagulator, heater probe or any other device that destroys polyp cells.

When your gastroenterologist uses any of these methods for an ablation of either a non-bleeding angiodysplasia or polyp tissue from a site where tissue was not removed during the same procedure, you can report:

• 44401 -- Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed)

• 45320 -- Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) 

• 45346 -- Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) 

• 45388 -- Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).

Caution: Don’t report code 45388 when the gastroenterologist uses any of the following methods to ablate the remainder of a polyp immediately after removal of most of the polyp by another method:

1. If the gastroenterologist ablates remaining polyp tissue with hot biopsy forceps after removing most of the polyp with the hot biopsy forceps, report 45384.

2. When the physician uses bipolar cautery for ablation of remaining polyp tissue after a cold biopsy polyp removal, opt for 45380 on your claim. Do not report either ablation (45388) or control of bleeding (45382, Colonoscopy, flexible; with control of bleeding, any method).

3. “The gastro can use the tip of the snare to ablate remaining polyp tissue after snare cautery removal of a larger polyp,” Weinstein says. This is similar to monopolar cautery. “You should code snare tip-technique ablations after a snare polypectomy with 45385 only,” he adds.

Don’t Ignore Control of Bleeding Codes

No, you are not reading wrong. Many of the techniques that gastroenterologists may use for control of bleeding and for ablation are the same. Even the code definitions can be misleading.

Take a look at these cauterization codes:

• 45317 -- Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

• 45334 -- Sigmoidoscopy, flexible; with control of bleeding, any method

• 45382 -- Colonoscopy, flexible; with control of bleeding, any method.

You can use them in the following situations:

1. If the gastroenterologist controls bleeding from a polypectomy site several days after the initial polyp removal

2. If the gastro treats diverticulosis with hemorrhage (562.12, Diverticulosis of colon with hemorrhage)

3. If the gastro treats diverticulitis with hemorrhage (562.13, Diverticulitis of colon with hemorrhage) or

4. If the gastro treats angiodysplasia with active hemorrhage (569.85, Angiodysplasia of intestine with hemorrhage).

Note: Code 562.12 changes to K57.31 (Diverticulosis of large intestine without perforation or abscess with bleeding), 562.13 crosses to K57.33 (Diverticulitis of large intestine without perforation or abscess with bleeding), and 569.85 walks to K55.21 (Angiodysplasia of colon with hemorrhage) after the ICD-10 transition from Oct. 1.

Stop: You cannot in any circumstance bill for code 45382 if the physician himself causes the bleeding during the colonoscopy. In such a scenario, for example, you can only report the base code such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).