Health Information Management

More colonoscopy coding considerations

APCs Insider, July 1, 2004

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QUESTION: What is the appropriate CPT-4 code(s) assignment when a physician performs a colonoscopy by cold-biopsy forceps, obtains a specimen for pathology, and then applies bipolar cautery?

ANSWER: According to CPT Assistant January 2004, the code assignment for cold-biopsy forceps removal of a polyp during a colonoscopy is 45380, "Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple." This answer is an update from the CPT Assistant January 1996, which stated 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.

According to the American Gastrointestinal Association, CPT code 45380 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. 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 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 in 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. Code 45385 should not be used for a report describing the removal of a small polyp by biopsy or cold forceps technique. Stay tuned for the July 2005 CPT Assistant for further clarification.

Note: Depending on the facts in the endoscopy report, the following advice applies:

  • If the physician applies biopolar cautery to the site in order to control bleeding after the cold biopsy forceps removal, this would be included in the overall procedure. No separate code is assigned.
  • If the entire lesion or polyp was removed using bipolar cautery after the initial biopsy of the same lesion or polyp, regardless of how the biopsy was performed use only code 45384, "Colonoscopy, with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery."
  • If only a biopsy was performed without removing the entire polyp or lesion, use code 45380.

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