Wiki 45380 and 45383

[Lisa Bledsoe]

One of my docs is wanting to code 45380 and 45383 for the same polyp. He clearly documents polyp removed by biopsy forceps and states "the margins were then fulgurated with Gold probe...". I'm usually confident in my colon coding, but is it possible to code 45383, 45380-51? The 1/04 CPT Assistant article leads me to believe I can, but it is not clearly stated. Any thoughts?
Thanks!
Lisa

 

[elenax]

I got this information from the Gastroenterology Coding Alert and I hope this helps!

"Don't report 45383 when the gastroenterologist uses any of the following methods to ablate the remainder of a polyp immediately after removal of most of the poly by another method, Weinstein says:
1. If the gastro removes and then ablates with hot biopsy forceps, report 45380 instead.
2. When the physician uses bipolar cautery for removal followed by ablation, opt for 45384 on your claim.
3. You should code snare-technique removal followed by ablations with 45385.
Hot forceps bipolar cautery: When the gastroenterologist both removes and cauterizes a polyp simultaneolusly using hot biopsy forceps, you should use 45384. You can also apply this code when the physician uses either a monopolar hot biopsy forceps or a bipolar cautery forceps, Weinstein says"

 

[Lisa Bledsoe]

Thank you - that is helpful.