Gastroenterology Coding Alert

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Question: My doctor performed a colonoscopy with polyp removal by cold biopsy forceps, and the polyp was removed. Should I assign 45383? Missouri Subscriber Answer: Code 45383 describes ablation of a tumor. "The tumor, polyp or other lesions are identified and ablated [destroyed] by laser or other method," states Coding Illustrated. Cold biopsy forceps are used to biopsy or remove a tumor, not to destroy it. No CPT code specifically states "cold biopsy forceps." Therefore, a controversy has arisen as to whether gastroenterologists and coders should assign CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) or 45385 ( with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Some experts recommend using the biopsy code for a cold forceps biopsy, and the snare code for a snare (cold or hot). They reserve 45385 for when the physician states a snare was used. CPT Assistant January 1996 says, "The appropriate code for a colonoscopy with removal of a polyp by a cold biopsy is 45380 or 45385 depending on the actual technique employed." The article suggests using 45380 for a partial removal of a polyp, and 45385 for a removal of the entire polyp. Removal by forceps differs from the snare technique in that the jaws at the tip of the forceps are used to surround the polyp and remove it, as opposed to a loop, according to CPT Assistant.

However, the work involved in removing a polyp using cold biopsy forceps is about the same as biopsying the area. Therefore, carriers may not approve of billing 45385, which has 7.95 facility relative value units (RVUs), as opposed to 45380, which has 6.7 facility RVUs. In addition, your doctor may have a difficult time explaining to an auditor that a removal of a lesion using cold biopsy forceps is the same as using the snare technique. In any case, attempting to code using cold biopsy forceps according to an analysis of the work involved or the definitions of 45380 and 45385 is speculative at best. Therefore, make sure to ask your insurers for their interpretations. If possible, obtain their recommendations in writing. Proving that you code based on your carriers' instructions will protect you in the event of an audit.