Gastroenterology Coding Alert

Although colonoscopy is one of the procedures most frequently performed by gastroenterologists, there is often uncertainty over which code should be used to report a surgical procedure such as a polypectomy or control of bleeding. Coding is difficult because the devices used during a surgical colonoscopy can serve multiple purposes and are often referred to by different names. Using the correct code not only boosts reimbursement but can prevent problems during an audit.
 
This article will look at the five most frequently reported codes for surgical colonoscopies and discuss under what circumstances these codes are most commonly used.

 
45385 -- colonoscopy; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
 
 
When a polyp is removed during a colonoscopy it is likely to be removed with the snare technique (45385). The electrocautery snare, a wire loop that heats up and is used to shave off the polyp, is the most common method of removal, especially for larger polyps, says Donald Vidican, MD, a gastroenterologist in Rockford, Ill.
 
Conversely, most often a snare employed by a gastroenterologist will be for a polypectomy. It is conceivable that the heat from the snare could be used to control bleeding, but it would be most unusual for a gastroenterologist to use it for that purpose, Vidican says. The snare is also referred to as a hot snare. There are also monopolar and bipolar snares. Regardless of the terminology, all of these would be reported with 45385 if used during a polypectomy.

 
45384 -- colonoscopy; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 

 
Hot biopsy forceps, which snip off and cauterize the polyp at the same time, are used to remove, and not just biopsy, smaller polyps, says Vidican, who adds that he seldom uses hot biopsy forceps.
 
The description also includes the use of bipolar cautery, where "current runs from one portion of the tip of the device to another portion," according to the spring 1994 issue of the CPT Assistant. Hot biopsy forceps, in contrast, use a monopolar current, requiring the use of a grounding pad placed on the patient's body.

 
45383 -- colonoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

 
From its description, the ablation code may look like a hodge-podge, grab-bag code for all methods of removing a polyp that are not by snare technique or hot biopsy forceps. After all, the term "ablation" means only "to remove esp. by cutting," as noted in Webster's Medical Desk Dictionary. In gastroenterology, however, the term is often used more specifically to refer to the use of argon plasma coagulators (APC), lasers, heater probes or other devices to cauterize a polyp or the remnants of a polyp to the point where it is destroyed.
 
The ablation code is often used in this manner for a follow-up colonoscopy. If the polyp removed during the initial colonoscopy is benign, the gastroenterologist may have the patient come back in a few months for a follow-up colonoscopy, suggests Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. "If a large polyp was initially removed by snare, you know there are some cells that are still there, but you've already done so much burning and removal that you have the patient come for a follow-up colonoscopy to remove whatever is left over," he explains.
 
One of the more popular methods for destroying those leftover cells is to treat the site of the polyp with an APC, which uses argon gas to deliver thermal energy to a field of tissue adjacent to the probe. The APC probe is applied to the site of the polyp and cauterizes the tissue until all the cells are destroyed.
 
Cauterization done with an APC, laser, heater probe or any other similar devices to destroy any remaining polyp cells should be reported with the ablation code (45383), Weinstein says. However, not all follow-up visits to remove the remainder of a polyp will include ablation. Weinstein points out that the snare technique can also be used to remove the remainder of the polyp, in which case the snare-technique code (45385) should be reported.
 
Also, the use of these cauteries is not limited to ablation only. All of the methods mentioned (APC, laser, heater probe, etc.) are used to control bleeding.

 
45380 -- colonoscopy; with biopsy, single or multiple

 
This code refers to the use of cold biopsy forceps, which are a separate device from the hot biopsy forceps mentioned previously. Cold biopsy is done with disposable forceps, says Vidican, and is performed to take tissue samples during an endoscopy. They are called "cold" because there is no electric current running through them and no ability to cauterize any bleeding that may be caused by the forceps.
 
Debate over this code arises when cold biopsy forceps are used to remove a small polyp. The snare-technique code 45385 could be used to report this procedure, according to Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania Department of Medicine, where more than 30 gastroenterologists practice. She bases her recommendation on a brief article in the January 1996 issue of the CPT Assistant that specified if cold biopsy forceps are used to remove a portion of the polyp, the biopsy code (45380) is to be used. If the polyp is removed in its entirety, 45385 should be used.
 
Pohlig would also consider using the ablation code (45383) in this situation. "It is a destruction of the polyp, and the ablation code doesn't state that a particular method, such as a laser, has to be used," she says.
 
While admitting that many coding experts disagree on this matter, Weinstein would code any removal, partial or complete, that uses cold biopsy forceps with 45380. His reasoning is that the snare and ablation codes pay much more than the biopsy code, but it takes the same amount of work to remove a small polyp with cold forceps as to biopsy one. He also warns gastroenterology practices that citing a CPT Assistant article from many years past may not be much defense during a Medicare audit.
 
Pohlig says clarification is needed to settle this difference in opinion. The only official coding guideline that gastroenterology practices have is the AMA's CPT Assistant, she says, and most practices look to that publication for sound advice.

5. Control of Bleeding

 
45382 -- colonoscopy; with control of bleeding, any method

 
This is a particularly tricky code to work with because gastroenterologists will frequently perform control-of-bleeding procedures that are not separately billable. "If you cause the bleeding, you fix it for free," Weinstein says. "If you start it, you stop it no matter how complicated the technique."
 
If the bleeding is caused by a biopsy, for example, and the gastroenterologist uses an injection of epinephrine to control the bleeding, only the biopsy can be reported -- even though the code for control of bleeding pays much more -- because in the Correct Coding Initiative, the code for control of bleeding is a component of the biopsy code (as it is for all the other codes mentioned in this article). Control of bleeding cannot be billed separately for the session unless the bleeding occurs at a different site and was not caused by the actions of the gastroenterologist.
 
This code also causes confusion because many of the same cautery tools that are used for ablation can also be used to control bleeding. An APC or a heater probe, for example, can be used to cauterize bleeding blood vessels, Vidican points out.
 
In these situations, it is often the diagnosis that will point to whether an ablation or a control-of-bleeding code should be used. Arteriovenous malformations, diverticulosis and bleeding from the site of a polyp that was removed a week ago will be common diagnoses that call for a control-of-bleeding code, Weinstein says.
 
Although there are many methods to control bleeding, the code can be reported  only once. "The code says 'any method' to control bleeding," Weinstein explains. "That could be an injection or clips, you don't have to use heat. You may use three or four methods to stop the bleeding, but only bill one code."
 
Note: While this article has focused specifically on the surgical colonoscopy codes, much of the information presented will apply to the surgical esophagoscopy and upper gastrointestinal endoscopy.