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Coding Corner: Test Yourself: 3 Keys to Healthy Polypectomy Coding

Amount, technique, definitions give away codes

Think you know the ins and outs of coding polypectomies? Take this quiz and see if you know where and when to report each polyp removal code.

Question 1: The physician performs a screening colonoscopy, and he biopsies what appears to be a colonic polyp using a cold biopsy forceps. But you read on the pathology report that it's an "unremarkable colonic mucosa" and that "no adenomatous epithelium is seen." Which code should you report?

Answer 1: Because no code exists in CPT that specifically describes cold biopsy forceps procedures, many physicians believe you should report code 45380 (Colonoscopy ...; with biopsy, single or multiple) whenever the doctor uses this technique. "A polypectomy using a cold biopsy forceps should be coded as a biopsy," agrees Cecile Katzoff, MGA, vice president for consulting services at the American Gastroenterological Association. While CPT previously advised coding cold biopsy procedures with the code for snare technique, they've reversed their opinion, Katzoff says. They decided that procedures "using a cold biopsy forceps are most like a biopsy, and therefore should be coded as a biopsy," she says. This change appears in the January edition of CPT Assistant.
While the complete tissue removal in this case may entice you to report 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), don't let it fool you - just because it looks like a polyp doesn't mean it is one. Your best choice would be 45380, because this code doesn't assume the tissue is a polyp and accounts for the cold forceps biopsy.
Question 2: During a colonoscopy, the physician discovers a polyp. The documentation states that he "debulked the majority of the polyp with the biopsy forceps and then cauterized the rest to completely remove the polyp." The physician believes code 45380 is appropriate. Which code should you report?
Answer 2: You have several possibilities here, due to the doctor's use of multiple techniques during the procedure: 45380 (the physician's choice), 45383 (... with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique), 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] with hot biopsy forceps or bipolar cautery), and 45385.
The coding gets tricky when you start eliminating codes. Let's say you discard 45383 because the polyp was indeed "amenable to removal by bipolar cautery." This choice would imply that you should instead select 45384, which specifies removal by this method, among others. But here's the deal: The documentation doesn't exactly name "hot biopsy forceps" or "bipolar cautery," so you would need to query the doctor to choose the right code.
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- Published on 2004-02-09