Gastroenterology Coding Alert

Clue In to Technique
 
 Unfortunately, nothing in CPT's description of the CPT 45380 or 45385 colonoscopy codes mentions "cold forceps" or distinguishes between removal of whole and partial polyps, says Sherri Brasher, an insurance and billing specialist at a physician practice in Indiana. So when gastroenterologists use endoscopic instruments, make sure they document which tools they placed on the end of the instrument, she says, because those tools signal the technique they used. For example, when performing a cold biopsy, the physician uses a biopsy forceps not a snare so you'd code this as 45380. "We don't feel comfortable using 45385 when that [snare] technique is not applied," she says.
 
On the other hand, Brasher says the advice in a 1996 CPT Assistant still holds: If the physician uses cold biopsy forceps to remove a portion of a polyp, you should use 45380. If the physician removes the entire polyp, even without a snare, use 45385. Published by the AMA, CPT Assistant says the code you use should depend on the "actual technique employed" when removing a polyp via a cold biopsy.
 
Some experts have recommended using 45380 for a cold forceps biopsy and using the snare code (45385) for a cold or hot snare. Brasher's office group decided to base their colonoscopy coding on the techniques they used because that can be justified easily to an insurer.
 
Many gastroenterology coding experts think that you should use 45380 for both a polypectomy and biopsy because the physician performs both with cold forceps.   

They consider that the amount or work for any procedure using cold forceps is the same as biopsying the area, whether it's for a partial or complete removal, so if you report a snare (45385) or ablation code (45383), you could be doing so fraudulently. In addition, you may have trouble getting paid for 45385 because some carriers won't approve it if the physician doesn't document the use of the snare.

Consider the Whole Versus Its Parts

 AMA guidelines primarily distinguish between the codes by the amount of polyp removed. For a partial polypectomy, they advise 45380, and for a complete polypectomy, 45385 regardless of instruments used, says Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates.
 
One explanation for this approach is that coding terminology and clinical terminology are different, says Margaret Lamb, RHIT, CPC, at Great Falls Clinic in Great Falls, Mont. For coders, a biopsy means removing a portion of tissue to determine its pathology and is a diagnostic procedure. An excision or removal, however, is the removal of the entire lesion and should be both therapeutic and diagnostic. But many physicians call a complete removal a "biopsy" because they are sending the tissue to pathology for diagnosis. There is no justifiable reason to downcode a removal (45385) to a biopsy (45380), Lamb says, "unless only a portion of the polyp is being removed."

 "The CPT Assistant states that you should use 45385," Lamb says, and if you undergo an audit, you use this source for guidance in the absence of clear instructions in the CPT book. "Whether you agree with the CPT Assistant clinically is irrelevant" because it is an official source, she adds.
 
And the Coders Desk Reference, which also discusses tissue samples versus removals, offers justification for coders who take this position, Lamb says. The guidebook states that for 45380, "the physician performs colonoscopy and obtains tissue samples," and for 45385 "the physician performs colonoscopy and removes a tumor, polyp or other lesions."

Is It a Polyp or Not?

According to Michael Weinstein, MD, a gastroenterologist in Washington, D.C., you should code 45380 any time the doctor uses cold biopsy forceps. But even that straightforward rule can get confusing when you take the pathology report into consideration. For example, suppose the physician performs a screening colonoscopy and biopsies what looks like a colonic polyp. The pathology report says that it's an "unremarkable colonic mucosa" and "no adenomatous epithelium is seen." In other words, no polyp is actually found. Although the complete tissue removal may signal you to use 45385 in this case 45380 doesn't specify polyp removal Weinstein still suggests using 45380. "It wasn't a true polyp. It just looked like a polyp," he says. "It is always that code [45380] when a cold biopsy forceps is used, no matter what the pathology shows. A cold biopsy is a cold biopsy."  Whether you biopsy or remove a small polyp with cold forceps, the same amount of work is involved, he says.
 
Weinstein also warns that in case of an audit, explaining to the auditor how removing a lesion with cold biopsy forceps is the same as using the snare technique (43585) could be difficult.