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Tip of the Week: Know when to report CPT code 45383 versus 45384

APCs Weekly Monitor, December 7, 2007

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If you're removing a polyp, and you report CPT code 45383, ensure that the physician documented that he or she ablated or destroyed the lesion. This is the documentation that drives code selection. The January 2004 CPT Assistant discusses this code briefly. The reference indicates that you should report this code when a physician destroys a polyp using almost any method other than those that other mechanisms identify and that different codes represent.

Paraphrased instruction from CPT Assistant states that the definition of code 45383 can be misleading because the definition only states what techniques physicians should not use (e.g., biopsy forceps [code 45384], bipolar cautery [code 45384], and snare [code 45385]). Physicians should not use these techniques because it might not be possible to actually remove the lesion. The physician can perform the ablation of the tissue (e.g., tumor, polyp, or other lesion) with many different types of devices (e.g., heater probe, bipolar cautery probe, argon laser, etc.) regardless of whether the physician obtains a sample with biopsy forceps before the he or she applies the ablative device.

A paraphrased instruction from CPT Assistant also states that technique drives code selection. Therefore,you would code the hot biopsy using CPT code 45384. For the ablation/destruction by methods other than hot biopsy, snare, or cold biopsy technique, report code 45383.

(The above tip was excerpted from the December issue of Briefings on APCs).

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