Outpatient Facility Coding Alert

Pay heed to the physician’s note for method and location.

When a physician at your facility performs a colonoscopy -- whether screening or diagnostic -- and removes one or more polyps, you need to zero in on four codes to describe the service. Choosing the wrong code could cost your group more, and failing to report a legitimate additional code could cost you even more. Pay attention to the physician’s documentation about polyp location and removal method, and use that information to pick the right code(s) from the following four coding options.

Choose CPT® 45385 for Snare Technique

The most common method that physicians use to remove polyps during a colonoscopy is the snare technique. The method employs an electrocautery snare -- a heated wire loop that shaves off the polyp. If that description fits the surgeon’s op note, report 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Physicians could theoretically use these snares, also called “hot snares,” for cautery as well, but that’s unusual. A snare has electrocautery on it, but you’re not ablating the polyp. In fact, physicians commonly use the snare technique for larger polyps that would not lend themselves to ablation.

Look at CPT® 45384 for ‘Hot’ Forceps

Sometimes the physician both removes and cauterizes a polyp simultaneously using “hot” biopsy forceps -- forceps with an electric current passing through them. In those circumstances, you should use 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps).

Physicians often use this technique for smaller polyps. You can also apply this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps.

Turn to CPT® 45388 for Ablation Only

Your physician won’t commonly remove polyps by ablation -- that process leaves nothing for the physician to submit to pathology for diagnosis. Instead, you’ll usually see ablation when the physician discovers remnants of previously removed polyps from an earlier colonoscopy. The technique involves using an argon plasma coagulator (APC), heater probe, or other device to destroy any remaining polyp cells and cauterize the site. Less often, the physician might ablate a small polyp that he can’t remove by other techniques.

When your physician documents any of these methods, report the service with 45388 (... with ablation of tumor[s], polyp[s], or other lesions[s][includes pre- and post-dilation and guide wire passage, when performed]).

Be careful: You shouldn’t apply 45388 when the doctor uses hot biopsy forceps, bipolar cautery, or snare technique for the ablation.

Report CPT® 45380 for ‘Cold’ Forceps Even for Polyps

Sometimes the physician removes a polyp with forceps that have no electric current -- thus the term “cold.” 

“Cold forceps are rare for polypectomy,” says Joseph A. Lamm, CPC, reimbursement specialist  for Stark County Physicians in Massillon, Ohio. That’s because the physician usually chooses one of the other methods that allows him to cauterize the site to control bleeding.

But on occasion, the physician will use these forceps for a partial polypectomy or in an area of the bowel without significant blood supply, such as the lower anal canal. In those cases, you should report 45380 (... with biopsy, single or multiple), even though the procedure is a polypectomy and not a biopsy. 

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