Gastroenterology Coding Alert

Question: My doctor says that during a colono-scopy a polyp is discovered. He "debulks the majority of the polyp with the biopsy forceps and then cauterizes the rest to completely remove the polyp." He thinks the code is 45380. I'm waffling between 45385 and 45383. Which is correct?

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Answer: Colonoscopy codes are tricky because they use the specific technique employed during the procedure to differentiate between services. Codes describe procedures that employ biopsy, removal of foreign body, dilation, hot biopsy or bipolar cautery treatment, snare treatment, ablation of lesion not amenable to treatment by the above, and control of bleeding, any method.

In the example given, the coder is deciding among 45380 (Colonoscopy; with biopsy, single or multiple), 45383 (... with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

It is important before making any decision on how to code this procedure to take a detailed look at the physician's notes. You can only code for each technique if it is specifically described in the patient's records.

During any endoscopic procedure, if the same lesion is biopsied and later removed during the same operative session, then the code for the removal of the lesion is the only one reported. For example, a colonoscopy is performed that includes the biopsy of a lesion in the transverse colon. This lesion is removed during the same session by snare technique. In this case, code 45385 is used.

Unless your doctor specifically documents use of hot biopsy forceps, bipolar cautery, or snare technique, you should not use 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). If your doctor actually used a bipolar cautery to remove the rest of the polyp, code 45384 would be appropriate. It is reasonable to use only code 45385 in the above scenario because the polyp was completely removed. This would conform to an explanation given in the CPT Assistant from 1996. If you are worried about explaining the seeming discrepancy in the documentation, use code 45380 alone.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.