Gastroenterology Coding Alert

Because the CPT does not specifically use the phrase cold forceps or cold biopsy forceps in any of its definitions, gastroenterologists often are unsure which code to use for the procedure. But there are several codes physicians can use to ensure proper billing for these procedures.

Forceps that use an electrical current to remove the polyp are referred to as hot biopsy forceps or a cautery biopsy, explains Michael Weinstein, MD, an American Medical Association (AMA) CPT advisory committee member from Washington, D.C. Cold biopsy forceps do not use an electric current.

Although the phrase cold biopsy forceps is not mentioned in CPT, Weinstein says that there are codes for both hot and cold removal techniques. For example, CPT 45380 (colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) is for use with the cold forceps, while 45384 (colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) specifically refers to hot biopsy forceps.

For an upper gastrointestinal endoscopy (EGD) with cold forceps, use code 43239 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple), while code 43250 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) specifically refers to an EGD with hot biopsy forceps, says Weinstein.

Controversy Over Coding for Complete Removal

If a small polyp is being completely removed with cold forceps during a colonoscopy and not just biopsied, then gastroenterologists may use code 45385 (colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), according to Cathy L. Klein, LPN, CPC, a senior consultant at Health Care Economics Inc., an Indianapolis-based healthcare consulting firm that also maintains the coding hotline for the American College of Gastroenterologists.

A biopsy is when only a piece of the lesion is removed and then sent to pathology for a report, she explains. In a polypectomy, the entire lesion is removed and may also be sent to pathology for analysis.

If cold forceps are used during a colonoscopy when the intent is to do just a biopsy, then Klein also recommends using code 45380. In her opinion, however, a gastroenterologist generally intends to remove the polyp in its entirety during the procedureunless it is too large to remove endoscopically.

There is a significant difference in reimbursement between using 45380, which has a relative value unit (RVU) of 9.98 and 45385, which has 12.75 RVUs.

Use of Snare Technique Code Questioned

While acknowledging that his opinion is not popular, Weinstein disagrees with the use of 45385 and suggests that gastroenterologists stick with 45380 for colonoscopies with cold forceps biopsiesregardless of whether the polyp is completely removed or not.

Because the amount of work being performed when removing a lesion with cold forceps is the same as biopsying one, Weinstein feels that gastroenterologists should charge only for the biopsy. The CPT coding for procedures is organized based upon techniques or methods and not based upon the diagnosis, outcome or tissue results, he explains. Clearly there is no difference in the amount of work when cold biopsy forceps are used to sample a mass or to remove a tiny lesion.

He also thinks that there are situations when a HCFA auditor might question the use of the code for the snare removal technique. When a small lesion is removed, it often is not a polyp but rather an inflammation or even normal tissue, he says. If records are audited, how would you explain that the colonoscopy with cold biopsy of normal tissue was colonoscopy with removal of polyp by snare technique? An auditor could be justified in calling this fraud.

Because the policies of HCFA and commercial insurance payers are unclear regarding how to code for cold biopsy forceps, gastroenterologists should contact their local Medicare and private insurance payers to get instructions for handling these claims.