Gastroenterology Coding Alert

Learn what code you-ll always use for cold biopsy forceps

If you don't code your gastroenterologist's polyp removal method right, you-ll be staring down a denial. Bottom line is that you have to consider many factors when the gastroenterologist performs a colonoscopy with a polypectomy -- the type of scope, the surgical technique, and the polyp location.

Check for Polypectomy Details

First, read the gastroenterologist's dictation and verify that he performed a colonoscopy.

If the physician performs a polypectomy as well, you need to find out which method the physician used to remove each polyp (either with biopsy or snare technique). In the case of multiple polyp removal, you must determine:

- where the physician located each polyp on the colon

- whether the polyps were in separate locations, or

- if the physician removed a large polyp in pieces from one location.

Why? This is important because the number of polyp locations and the methods used may affect the number of codes you can allowably report on your claim.

Cold Biopsy Forceps Mean 45380

Your gastroenterologist may use cold forceps to remove a polyp. 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 report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). Also, if the gastroenterologist completely removes a small polyp using cold biopsy forceps, you should report 45380 as well, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

-Cold biopsy forceps are always 45380,- agrees Danielle Billieux, billing specialist at Hampshire Gastroenterology Associates in Florence, Mass.

Use 45385 for Total Polypectomies

A partial polypectomy is usually a cold biopsy, whereas physicians typically perform a total or entire procedure with an electrocautery snare (a heated wire loop that shaves off the polyp).

When the gastroenterologist uses snare technique during a total polypectomy, you should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Reserve 45382 for Control of Bleeding

No, it's not a trick: Gastroenterologists may use many of the same techniques for cauterization (to control bleeding) and for ablation -- and the code definition can also be confusing. But the defining factor is the clinical situation and diagnosis, Weinstein says.

For example, use 45382 (Colonoscopy ...; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) in the following situations:
 
- when the gastroenterologist controls bleeding from a polypectomy site several days after the initial polyp removal

- when the gastro treats diverticulosis with hemorrhage (562.12, Diverticulosis of colon with hemorrhage)

- when the gastro treats diverticulitis with hemorrhage (562.13, Diverticulitis of colon with hemorrhage)

- when the gastro treats angiodysplasia with hemorrhage (569.85, Angiodysplasia of intestine with hemorrhage).

Note: You cannot separately bill 45382 if the gastroenterologist causes the bleeding during the colonoscopy. If, for example, the gastro causes bleeding during a diagnostic colonoscopy and has to cauterize, you should report only 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).

Why? Although the gastroenterologist had to use cautery to control bleeding, it is included in the 45378 surgical package if he caused the bleeding.

If Gastro Ablates Polyp, 45383 Is Your Code

If your physician performs an ablation during a follow-up colonoscopy, all of your coders should be familiar with the procedure. Ablation usually refers to a cauterization technique the physician performs with an argon plasma coagulator, heater probe or other device that destroys any remaining polyp cells after a prior colonoscopy in which the surgeon removed a larger polyp using a snare.

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 notremoved during the same procedure, you should report 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Be careful: Don't report 45383 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, Weinstein says:

1. If the gastroenterologist ablates remaining polyp tissue with hot biopsy forceps after removing most of the polyp, report 45384 (- with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

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 (45383) or control of bleeding (45382).

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

Apply 45384 for Hot Forceps Bipolar Cautery

When the gastroenterologist both removes and cauterizes a polyp simultaneously using bipolar forceps, you should use 45384. You can also apply this code when the physician uses either a monopolar hot biopsy forceps or a bipolar cautery forceps, Weinstein says.

Multiple Polypectomies With Snare? Attach Mod 22

Usually, gastroenterologists remove polyps -- especially larger ones -- during a colonoscopy with the snare technique. In this situation, use 45385.

If there are many polyps located in various regions -- and the physician spends a lot of time removing the polyps -- you should report 45385 and append modifier 22 (Unusual procedural services) so the carrier will compensate and reimburse for her extra time.

There is no standard, but double the usual amount of time is reasonable for using modifier 22. For example, if the gastroenterologist spends 10 extra minutes on a procedure that normally takes 40 minutes, don't use modifier 22.

To increase your modifier 22 claim's chances of success with the carrier, remember to:

- record the exact amount of time the procedure normally takes

- record approximately how much longer the procedure took in this scenario.