Health Information Management

Proper coding for polyp removal

APCs Insider, March 26, 2004

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QUESTION: When a patient has a colonoscopy with removal of two polyps, both from the sigmoid, both removed by snare technique, we have been coding them with 45385. Recently, we were told to add a second 45385 and modifier -59. Is this correct? How do you code a polyp removed by cold biopsy technique?

ANSWER: According to CPT coding guidelines, it is not the number of polyps removed, but the different techniques used to remove colon polyps. Therefore, even though two polyps were removed from the sigmoid colon by snare technique, CPT code 45385 is reported once. Also pay attention to the CPT narrative, "with removal of tumor(s), polyp(s), or other lesion(s), by snare technique."

For removal of two colon polyps from the sigmod colon, one by snare technique and the other by hot biopsy technique, both 45385 and 45384 can be reported for the same encounter because two separate lesions were removed by two different techniques. Current Outpatient Code Editor (OCE) and Correct Coding Iniative (CCI) edits do not require modifier application from a hospital standpoint.

Finally, there is a dilemma with code assignment for cold biopsy forceps technique. CPT Assistant January 1996 states "CPT code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, most accurately describes the removal of the entire polyp using a cold biopsy forceps. The jaws at the tip of the forceps (as opposed to a loop) surround the polyp at its stalk and sever its attachment to the colon mucosa. The polypoid lesion is then sent for pathology analysis."

But pay attention to CPT Assistant January 2004 where the American Medical Association (AMA) reversed this answer to instruct removal of polyp with cold biopsy forceps should be assigned CPT code 45380 because the polyp is so small that it can be completely removed during the biopsy, which is often done with the cold biopsy forceps technique. This is a controversial answer at the moment due to the direct conflict regarding Medicare Endoscopic Biopsy Coding Guidelines, which state, "If a biopsy of a lesion is obtained and the remaining portion of the same lesion is excised, code only for the excision." The AMA has promised to publish a clarification in the near future, so stay tuned.

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