Gastroenterology Coding Alert

Question: My report says, "rectal polyps with cold biopsy polypectomy" and "random colon biopsies." Should I use CPT 45380 with modifier 59 or 45384 and 45380?

Montana Subscriber

Answer: You should use only 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the cold biopsy forceps polypectomy. Also count this as your code for the biopsy.

Because this code descriptor says "multiple," you'll report this code once, no matter how many biopsies or polypectomies your gastroenterologist performs. Remember, he is using the same technique in this scenario.