Gastroenterology Coding Alert

Question: Our gastroenterologist performed biopsies from the colon for histology and removed a rectal polyp. Both were done with cold forceps. The pathology-lab results came back as colitis and adenoma. Could these be billed separately, or should I bill 45380 once?

Alabama Subscriber

 
Answer: Because these procedures were performed at two separate sites, you can bill separately for the procedures. The biopsy should be reported with 45380, according to Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania Department of Medicine.
 
There is some debate over whether a different code can be used to report the removal of the polyp with cold biopsy forceps. Pohlig suggests using the colonoscopy with snare technique code (45385). She bases her recommendation on a brief article in the January 1996 issue of the CPT Assistant that specified if cold biopsy forceps are used to remove a portion of the polyp, the biopsy code (45380) is to be used. If the polyp is removed in its entirety, the article says 45385 should be used.
 
Pohlig would also be amendable to using the ablation code (45383) in this situation. It is a destruction of the polyp, and the ablation code doesnt state that a particular method, such as a laser, has to be used, she says.
 
Many gastroenterology coding experts, however, share your first inclination that 45380 covers both the polyp-ectomy and the biopsy because both were done with cold forceps. They feel the work effort for any procedure using the cold forceps is the same whether its a partial or complete removal, and that reporting the snare or ablation code would be fraudulent (or at least unethical) upcoding.