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Gastroenterology Coding Alert

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Hot Biopsy Technique Leads You To 45384

Published on Fri Sep 09, 2011

Question: Our GI saw a patient for endoscopic biopsy. The patient's mucosa was normal except for internal hemorrhoids and a raised sessile diminutive polyp in the sigmoid colon that was ablated through hot biopsy forceps. What CPT describes this procedure? New Jersey Subscriber Answer:  In general, the technique (cold biopsy forceps, hot biopsy forceps, or snare technique) should drive your code selection. However it is possible to ablate a polyp or lesion not amenable to removal with many different devices including all of the above techniques plus argon plasma coagulation, gold probe bipolar cautery, and other methods. The answer to your question depends on whether any of the diminutive polyp was removed for pathology analysis. If a specimen was removed then you should code the hot biopsy using 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). [...]
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