Gastroenterology Coding Alert

Question: How should I code for a colonoscopy with biopsies and the removal of a polyp using cold forceps? The physician's notes say, "Colonoscopy with biopsies and cold biopsy removal of polyp." The biopsies are from the cecum, and the polyp is removed using cold forceps from the rectum.

Iowa Subscriber

Answer: 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, use code 45385.

Coding for the procedure you described is tricky because the answer depends on the exact circumstances of the procedure. The 1996 CPT Assistant states that 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) should be used for the removal of portions of the polyp with cold biopsy forceps. 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) is used to describe the removal of the entire polyp. If the doctor does biopsies of other sites and also removes a polyp, then you can code 45385 and 45380 appended with modifier -59 (Distinct procedural service). Be sure to analyze the operative notes to determine if there were biopsies of multiple sites with the removal or only the biopsy and removal of one polyp.

Clinical 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.