General Surgery Coding Alert

Question: We have general surgeons at our office who perform many colonoscopies. We're uncertain about the word "ablation," which our medical dictionary defines as "removal of a part, as by incision." Does this mean we can use 45383 for polyp removal by cold biopsy, which would involve sending a specimen to pathology?

Michigan Subscriber

Answer: Although you might possibly use 45383 (Colonoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for a polyp removal by cold biopsy, that's probably not the best code choice. Surgeons don't typically send a specimen to pathology following an ablation procedure.

The term "ablation" more commonly describes an erosive or corrosive removal, such as laser, cryotherapy, or chemotherapy. If the surgeon describes polyp ablation by any of those methods, 45383 would clearly be the best choice.

Better: When the surgeon removes a polyp by "cold" biopsy (meaning that the knife doesn't use an electrical current), a better code choice would be CPT 45380 (... with biopsy, single or multiple). You would expect to send a specimen to pathology with this code.

Caveat: The language in the documentation may strongly guide which code would be appropriate. CPT® does include "excision" as one of the choices for "destruction" in some cases, so using 45383 for a cold knife polyp removal might be appropriate, under some circumstances.