Gastroenterology Coding Alert

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?

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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). This code describes a procedure wherein the physician uses bipolar forceps to both remove and cauterize a polyp simultaneously. You would also apply this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps. However, if the polyp was not amenable to removal then you should code using 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique)

Quick fact: The instrument used in a colonoscopy is a flexible, thin tube with a video camera and light at the end called a colonoscope. Sometimes, the physician passes other instruments (i.e., biopsy forceps) through the colonoscope to perform procedures such as tissue biopsy and polypectomy. Several other CPT codes pertain to colonoscopy procedures besides 45384. For instance, you would code 45385 (Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for polyp removal using snare technique.

When coding for colonoscopy, you should consider a number of factors as guide for your code selection:

• Was another procedure(s) performed during the diagnostic colonoscopy?
• If so, what was the procedure(s)?
• What was the technique used?
• Was the lesion removed for pathology analysis?
• What instruments were used?