Outpatient Facility Coding Alert

Question: How do I code a biopsy and removal of a colon polyp using a cold forceps technique? I see code options for hot biopsy forceps and snare techniques, but nothing referencing cold forceps.

Illinois Subscriber

Answer: Typically, the physician will only use a cold forceps technique to remove a portion of the tissue to have sent for biopsy. You may want to reevaluate the operative report to confirm that the provider is removing the entire polyp, rather than a portion for biopsy.

The general consensus among most coders is that when the provider uses a technique other than snare or hot biopsy forceps, such as cold forceps, you should report code 45380 (Colonoscopy, flexible; with biopsy, single or multiple). However, a January 2004 CPT^® Assistant article seems to state otherwise:

• “CPT^® code 45380 does not describe a specific technique. The terminology is accepted and understood by colonoscopists to mean the use of a forceps to grasp and remove a small piece of tissue without the application of cautery. Colonoscopy reports may describe the biopsy of a lesion or polyp using a cold forceps or may describe the biopsy without mentioning the specific device. The biopsy may be from an obvious lesion that is too large to remove, from a suspicious area of abnormal mucosa, or from a lesion or polyp so small that it can be completely removed during the performance of the biopsy, which is often demonstrated with the cold biopsy forceps technique. The technique is the same and the service is reported with code 45380 regardless of the final histology of the piece of tissue obtained for analysis. Colonoscopy with removal by snare technique, 45385, should not be used for a report describing the removal of a small polyp by ‘biopsy’ or ‘cold forceps’ technique.”

While some coders use this CPT^® Assistant article to argue in favor of the use of code 45380 to report polypectomies using a cold forceps technique, the answer seems to be ambiguous, at best. While the American Medical Association (AMA) states that 45380 does not describe a specific technique, it further goes on to explain that 45380 typically involves the removal and biopsy of a “small” piece of tissue. Still, 45380 appears to be the “best” option available, despite its shortcomings. However, you also may consider the option of applying code 45399 (Unlisted procedure, colon). It is advised that you contact the payer to confirm that the operative report warrants submission of either code 45380 or 45399.

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