General Surgery Coding Alert

Let method lead you to the right polypectomy code -- every time.

When your general surgeon performs a colonoscopy -- whether screening or diagnostic -- and removes one or more polyps, you need to zero in on four codes to describe the service. Choosing the wrong code could cost your practice $$, and failing to report a legitimate additional code could cost you even more. Heed your surgeon's documentation about polyp location and removal method, and use that information to pick the right code(s) from the following four coding options.

1. Snare Technique Takes 45385

The most common method that surgeons use to remove polyps during a colonoscopy is the snare technique. The method employs an electrocautery snare -- a heated wire loop that shaves off the polyp. If that description fits your surgeon's op note, report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Physicians could theoretically use these snares, also called "hot snares," for cautery as well, but that's unusual. A snare has electrocautery on it, but you're not ablating the polyp. In fact, surgeons commonly use the snare technique for larger polyps that would not lend themselves to ablation.

2. Report 45384 for 'Hot' Forceps

Sometimes the surgeon both removes and cauterizes a polyp simultaneously using "hot" biopsy forceps -- forceps with an electric current passing through them. In those circumstances, you should use 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

Surgeons often use this technique for smaller polyps.You can also apply this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps, says Michael Weinstein, MD, a physician in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Wrong code could cost you: You'll want to be sure to correctly distinguish between snare technique and hot forceps -- Medicare pays $240 for 45385 but only $211 for 45384 (national facility total amount using conversion factor 28.3868) -- that's a difference of $29.

3. Use 45383 for Ablation Only

Your surgeon won't commonly remove polyps by ablation -- that process leaves nothing for the surgeon to submit to pathology for diagnosis. Instead, you'll usually see ablation when the surgeon discovers remnants of previously removed polyps from an earlier colonoscopy. The technique involves using an argon plasma coagulator (APC), heater probe, or other device to destroy any remaining polyp cells and cauterize the site. Less often, the surgeon might ablate a small polyp that he can't remove by other techniques.

When your surgeon documents any of these methods, report the service with 45383 (... with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Be careful: You shouldn't apply 45383 when the doctor uses hot biopsy forceps, bipolar cautery, or snare technique for the ablation.

4. 'Cold' Forceps Require 45380 -- Even for Polyps

Question: When is a polypectomy a biopsy?

Answer: When the forceps are "cold."

Sometimes the surgeon removes a polyp with forceps that have no electric current -- thus the term "cold." "Cold forceps are rare for polypectomy," says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio. That's because the surgeon usually chooses one of the other methods that allows him to cauterize the site to control bleeding.

But on occasion, the surgeon will use these forceps for a partial polypectomy or in an area of the bowel without significant blood supply, such as the lower anal canal. In those cases, you should report 45380 (... with biopsy, single or multiple), even though the procedure is a polypectomy and not a biopsy.