Gastroenterology Coding Alert

Question: I bill a colonoscopy with biopsy using CPT 45380 when my gastroenterologist uses "cold biopsy forceps," but I cannot find a CPT code for that. Should I use 45385 instead?

Kentucky Subscriber

Answer: The method takes precedence over the pathology.

When the gastroenterologist takes tissue samples with cold biopsy forceps, you should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). Also, if the gastroenterologist completely removes a small polyp using cold biopsy forceps, you should report 45380 as well.

What this is: Cold biopsy forceps are disposable forceps that the physician uses to take tissue samples during an endoscopy. No electric current passes through them -- thus the term "cold." You cannot use these forceps to cauterize bleeding that the forceps may cause.
You shouldn't report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), because this code denotes when the gastroenterologist uses a snare technique during a total polypectomy.

What this is: A partial polypectomy is usually a cold biopsy, whereas physicians typically perform a total or entire procedure with an electrocautery snare (a heated wire loop that shaves off the polyp).

Warning: If your gastroenterologist's documentation shows no evidence of a snare but you report 45385 anyway, this is a false report and could land you in an auditor's crosshairs.