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Gastroenterology Coding Alert

Reader Question:

Cold Biopsy Forceps

Published on Wed Dec 01, 1999

Question: What is the proper code to use for removal of a polyp with cold forceps?

Darlene Gehman
Upper Bucks Medical Associates
Sellersville, PA

Answer: When cold biopsy forceps are used to remove a portion of the polyp, the endoscopic biopsy code is used, says Susan Callaway-Stradley, CPC, CCS-P, a coding consultant and educator in North Augusta, SC. If the entire polyp is removed, the code for the snare removal technique should be used.

In the case of a colonoscopy, the cold biopsy code would be 45380 (colonoscopy with biopsy, single or multiple) if only a portion of the polyp is removed. If the entire polyp is excised, then use 45385 (colonoscopy with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).
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