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 [...]