Wiki Colonoscopy Screening with Biopsy

[dbertolino]

We have a patient who had a scheduled colonoscopy but the physician found lesions and biopsied them. The procedure was coded 45380 with a 33 modifier but was wondering if we should use 45385 with a 33 modifier instead. Which is more appropriate and why?

 

[Pam Warren]

45385 is used to report the removal of a tumor, polyp or lesion by snare technique. The tissue is almost always biopsied regardless of how it's acquired, but it's the technique that drives the code, not whether it's sent to pathology or not. Usually when they take a biopsy, they use just the little clip attached to the colonoscope to snip off a piece of tissue. So without documentation of the snare, you'd code only the 45380 for the biopsy.