Gastroenterology Coding Alert

Question: I have an op report that states, -At the hepatic flexure, a sessile polyp 10 mm by 4 mm was seen. The polyp was not bleeding. The polyp was completely fulgurated with APC/cold biopsy forceps. The polyp was retrieved.-

Can I report both 45383 and 45380 for the same area if the physician uses different techniques?


Colorado Subscriber

Answer: The short answer is -no.-

You cannot report two separate methods of removal for a single polyp. The more important question then becomes, should you report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) or 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)?

In this case, you may do better to report 45383. This method specifies -ablation - not amenable to removal by hot biopsy forceps, bipolar cautery or snare.- And, indeed, your op report states removal by argon plasma coagulator (APC), and 45383 allows slightly better reimbursement than 45380.

Bonus tip: To avoid denials, make sure you bill 45380 only once per colonoscopy--regardless of how many biopsies the physician performs. This applies even if the physician takes biopsies at several different locations (for instance, the transverse and descending colon).

Likewise, no matter how many tumors, polyps or lesions the doctor treats by the same or similar techniques, remember that the words -tumor(s), polyp(s), or other lesion(s)- in the descriptors of 45383, 45384 (hot forceps or bipolar cautery) and 45385 (snare technique) signal that you-re also restricted to reporting only one of these codes per colonoscopy.

When the physician uses different techniques to remove multiple polyps, however, you can bill multiple tumor, polyp or lesion removals, as long as you report each code only once per technique.

Example: The physician uses hot biopsy forceps and the snare technique to remove polyps during a single colonoscopy. In this case, you should report both 45384 and 45385. The payer should reimburse for both procedures (although you may face a multiple-procedure fee reduction for the second and any subsequent codes).

Important consideration: The physician would not normally use both hot biopsy forceps and snare technique during one procedure to remove different polyps. And requiring ablation to destroy remnants of small polyps that the gastroenterologist removed using cold biopsy forceps is unusual. Carriers might consider a high incidence of procedures with these combinations of techniques medically unnecessary and only an attempt to increase reimbursement.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the AMA's CPT advisory panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.