Part B Insider (Multispecialty) Coding Alert

Hint:  The device used doesn't determine the procedure code

Question: When performing a colonoscopy, the gastroenterologist found a miniscule polyp. He applied the tips of the hot biopsy forceps and fulgurated the polyp. He didn't retrieve any tissue for pathology. Is 45383 or 45384 the correct code for the procedure?

Answer: Because the gastroenterologist ablated rather than removed the polyp, use 45383 (Colonoscopy, flexible, proximal to splenic flexure; 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 determining keyword here is -ablation- rather than -removal.-

Why? The code's description 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.- Since the polyp was -not amenable to removal,- this clearly rules out the use of code 45384 (- with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

-When a colonoscopist documents the use of hot biopsy forceps to remove a lesion, code 45384 - is used to accurately report the service,- according to the January 2004 CPT Assistant (page 6). The American Medical Association (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).-

Caution: 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 tissue ablation -with 3many 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,- according to CPT Assistant.