jrgibson
New
During a colonoscopy screening the physician documents "there was a 1 mm flat white polyp removed from rectum with cold forceps". Would you use code 45385 or 45380?
The research that I have conducted thus far shows that code 45380 is more appropriate. According to CPT Assist Jan 2004 it states: "CPT code 45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple, 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. (See Figure 2) 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".
However, I have been informed by another source that a question was asked to AMA on how to code a colonoscopy with removal of a polyp using a cold forceps and their response was the following, "CPT code 45385, most accurately describes the removal of the entire polyp using a cold forceps". The source is not able to provide me a copy of the AMA's response and I would like to know if anyone has heard of this before.
The research that I have conducted thus far shows that code 45380 is more appropriate. According to CPT Assist Jan 2004 it states: "CPT code 45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple, 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. (See Figure 2) 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".
However, I have been informed by another source that a question was asked to AMA on how to code a colonoscopy with removal of a polyp using a cold forceps and their response was the following, "CPT code 45385, most accurately describes the removal of the entire polyp using a cold forceps". The source is not able to provide me a copy of the AMA's response and I would like to know if anyone has heard of this before.
