General Surgery Coding Alert

Question: When performing a colonoscopy, a surgeon finds a miniscule polyp. He applies the tips of the hot biopsy forceps and fulgurates the polyp. No tissue is retrieved for pathology. Is 45383 or 45384 correct?

Georgia Subscriber

Answer: Because the surgeon ablated, rather than removed, the polyp, you should use 45383.
 
The code's descriptor states, -with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery, or snare technique.- The two operative words are -ablation- and -removal.-
 
The difference between 45383 and 45384 is -ablate- and -remove.- The definition for 45383 clearly states -not amenable to removal.-
 
Code 45384 is for removal. -When a colonoscopist documents the use of hot biopsy forceps to remove a lesion [you should use] 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),- says CPT Assistant (January 2004).
 
The AMA goes on to concede, -The definition of 45383 can be misleading because it only states what techniques the codes should not be used for: hot biopsy forceps (45384), bipolar cautery (45384), and snare (45385).-
 
A physician may not be able to remove a lesion using one of those techniques. The continued discussion of 45383 emphasizes ablation over removal as the key difference between 45383 and 45384-45385.
 
The physician can perform the ablation of the tissue (tumor, polyp or other lesion) -with many different types of devices (heater probe, bipolar cautery probe, argon laser, etc.) regardless of whether a sample was obtained with a biopsy forceps before the ablative device is applied,- the AMA states in CPT Assistant.