Reader Questions:
Use 45380 for Cold Forceps Polyp Removal
Published on Thu Jun 01, 2006
Question: Our gastroenterologist performed a colonoscopy and found a sessile polyp in the sigmoid colon. He then did a cold forceps polypectomy. He found another sessile polyp in the ascending colon, and he snared and then cauterized this polyp with monopolar cautery. Also, he found diverticulosis in the descending, and colitis in the transverse, which he biopsied with standard forceps.
I want to code this procedure as 45385 with modifier 22. Can I can code each procedure separately with modifier 59?
Nebraska Subscriber Answer: You-re right about using 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), but you also need to add CPT 45380 -59 (- with biopsy, single or multiple; distinct procedural service) for the cold forceps polypectomy in the sigmoid colon and the biopsy of the colitis.
The AMA has stated that if a physician takes a polyp by cold forceps you should code it as a biopsy (45380). The description states -single or multiple,- so you can code 45380 only once for both cold forceps polypectomy and the colitis biopsy.