Gastroenterology Coding Alert

Question: While performing an EGD, my gastroen-terologist took a cold forceps biopsy to check for H. pylori from the antrum. Then he removed a polyp from the duodenal bulb with the cold forceps.

I'm not sure how to report this because even though cold forceps were used both times, they were at different sites and different specimens (one was a biopsy and one was a polypectomy). Should I use the same code twice?

Illinois Subscriber

Answer: You should report this as an EGD with biopsy (43239), and only report the code once. The CPT definition for this code states "biopsy, single or multiple." Your gastroenterologist could perform any number of biopsies, each at a different site, but as long as he or she is using cold forceps to perform the biopsies, you can report the biopsy code only once. While the second procedure was a removal and not a biopsy, what is still critical to most payers is that the same instrument (cold forceps) was used at both sites.

Some coding experts argue that you should code the cold forceps polypectomy as a removal by snare technique (43251). Because the latest version of the Correct Coding Initiative (CCI) bundles 43239 and 43251, reporting these two codes together will increase the payer's scrutiny of your claim. Because you would only get about $65 more for reporting the cold forceps removal as a snare removal, you need to consider whether that amount is worth the risk to your practice if it is audited.

For a complete discussion of coding for a removal by cold forceps, please see "Tips for Using the Five Most Common Colonoscopy Codes" on page 67 of the September 2001 Gastroenterology Coding Alert.