General Surgery Coding Alert

Question: The surgeon performed a “hot biopsy” for a polypectomy, according to the note. What is a hot biopsy and how would I code this?

Florida Subscriber

Answer: The hot biopsy technique involves the use of insulated monopolar electrocoagulating forceps to simultaneously biopsy and electrocoagulate tissue. Generally, the procedure is recommended for removal of diminutive polyps and to treat vascular ectasias of the gastrointestinal tract. This technique accomplishes ablation of the neoplastic tissue but provides the sample for the pathologist to diagnose.

Because of the risk of delayed perforation or bleeding, hot biopsy forceps are used much less frequently now than it was in the past. However, it is still utilized, so if the provider removes and cauterizes a polyp simultaneously using hot forceps, you can report the service.

Key: Which code you use depends on the type of scope procedure the surgeon is performing when removing the polyp. You might choose from one of the following codes, among others:

• 43216 (Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 43250 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 44365 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery)
• 45333 (Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy)
• 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 45308 (Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery).