Gastroenterology Coding Alert

Hint: Know when a biopsy is part of the code descriptor.

Several variables come into play when selecting the right codes for polyp removals from the colon, including the procedure method, the type of scope used, and the polyp location. Consider a few simple tips to ensure that you collect the right amount for your colonic polyp removals.

Check Removal Method

Mucosal polyps are commonly discovered during endoscopic evaluations of the GI tract. Adenomatous polyps are at risk for progression to cancer, which is why gastroenterologists typically remove them, having the tissue reviewed by a pathologist and setting up plans for appropriate timing of follow-up exams based on the details, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel member in Pasadena, California.

Polyps come in a wide variety of shapes and sizes, and may be present in challenging locations for removal. Typically, these lesions are removed by sigmoidoscopy, proctosigmoidoscopy, or colonoscopy. Sampling can be performed by prior cold biopsy, concurrent biopsy and ablation, or by retrieval of tissue after excision.

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

Hot Biopsy Forceps Provides Complete Ablation

Polypectomy with hot biopsy forceps provides improved hemostasis and more complete ablation of the neoplastic tissue, but may also increase the risk of delayed perforation or bleeding, and is a technique much less frequently used now than it was in the past because of this risk, Littenberg says. The physician can use either monopolar hot biopsy forceps or bipolar cautery forceps. If the gastroenterologist both removes and cauterizes a polyp simultaneously using hot forceps, depending on the type of scope, you can report:

• 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 report:

• 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), but this snare is increasingly used without cautery (“cold snare”) to remove polyps. When the gastroenterologist uses the snare technique, whether hot or cold, 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 should report 45309 (Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique).

Because these codes vary significantly in their requirements and payments, you should scrutinize the documentation to ensure that you have all the details on what was performed (and where) before you select a code. “Whether the polyp is removed by a single application of the snare, or removed in several parts (known as ‘piecemeal polypectomy’) doesn’t affect the coding,” Littenberg notes.

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 — hence 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 defer 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 tissue, 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 tissue.

When your gastroenterologist uses any of these methods for an ablation of either an 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 if any of the following circumstances apply to the ablation of the remainder of a polyp immediately after removal of most of the polyp by another method:

1. If the gastroenterologist ablates a remaining polyp tissue with hot biopsy forceps after removing most of the polyp with 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 gastroenterologist can use the tip of the snare to ablate remaining polyp tissue after snare removal of a larger polyp. This is similar to monopolar cautery. You should code snare tip-technique ablations after a snare polypectomy with 45385 only.

Know When Bleeding Control Is Included

It’s important to understand when you can separately report control of bleeding, and when it’s included in the ablation codes. 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 physician treats diverticulosis with hemorrhage (K57.31, Diverticulosis of large intestine without perforation or abscess with bleeding) or diverticulitis with hemorrhage (K57.33, Diverticulitis of large intestine without perforation or abscess with bleeding) as a freestanding technique to control the bleeding

3. If the gastroenterologist treats angiodysplasia with active hemorrhage (K55.21, Angiodysplasia of colon with hemorrhage) as a solo technique to control bleeding.

Stop: You cannot in any circumstance report code 45382 if the physician personally 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)), or more commonly, the code related to the type of polypectomy performed.