Internal Medicine Coding Alert

Question: When performing a colonoscopy, an internist 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 the correct code for the procedure?

Georgia Subscriber
 
Answer: Because the internist 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, code 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, is used to accurately report the service," according to the January 2004 CPT Assistant (page six).
 
The AMA goes onto concede that "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," states the AMA in CPT Assistant.

 -- Answers to You Be the Coder and Reader Questions answered/reviewed by Jim Collins, CPC, CHCC, president of Compliant MD Inc.; Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.