Gastroenterology Coding Alert

Question: My doctor says that during a colonoscopy a polyp is discovered. He "debulks the majority of the polyp with the biopsy forceps and then cauterizes the rest to completely remove the polyp." He thinks the code is 45380. I'm waffling between 45385 and 45383. Which is correct?

Answer: Colonoscopy codes are tricky because they describe the specific technique used during the procedure to differentiate between services. Codes describe procedures that use biopsy, removal of foreign body, dilation, hot biopsy or bipolar cautery treatment, snare treatment, ablation of lesion not amenable to treatment by the above, and control of bleeding, any method.

In the example given, the coder is deciding among 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), 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) and 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Important: Before deciding how to code this procedure, take a detailed look at the physician's notes. You can only code for each technique if it is specifically described in the patient's records.

During any endoscopic procedure, if the same lesion is biopsied and later removed during the same operative session, the code for the removal of the lesion is the only one reported. For example, a colonoscopy is performed that includes the biopsy of a lesion in the transverse colon. This lesion is removed during the same session by snare technique. In this case, 45385 is used.

Solution: The question states the physician used biopsy forceps to remove the majority of the polyp and then cauterized the remainder. Therefore, you should use 45380.