Colonoscopy with polypectomy using cold biopsy forceps


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Our surgeons and Gastroenterologists are doing the colonoscopies with polypectomy using the cold biopsy forceps. What CPT code is appropriate when the cold biopsy forceps are used? Where do we find the supporting documentaiton for this?

A polypectomy is only a removal of a polyp-not how it was removed.

Removal via cold biopsy forceps=45380

Removal via hot biopsy=45384

Removal via snare (any snare method) = 45385

Removal via ablation = 45383

Just look in your CPT book under those CPT codes and the procedure explanation is there.
I had one where the surgeon coded the snare and a biopsy but the report only stated that he removed all of the polyps by snare and sent them to pathology so I had the billing dept write off the 45380, would this be correct?
You would be correct Jen. If it doesn't state in the note "snare" and either "hot" or "cold" biospy it didn't happen.

I've seen doctors put "removed via hot snare biospy" in the note but when I've looked at the charge ticket given it shows snare and biopsy. Sorry, that's only a snare.
Two questions re: size of forceps and stoma

I have a physician who is convinced he should be able to use the hot biopsy code because he uses the bigger forceps, but believes it is better to remove them cold so he doesn't heat them up. Am I correct in telling him that no matter what size the forceps, if they are cold it is still code 45380?

Also, please advise on how you would code this scenario. Procedure notes say he did an upper endoscopy and an endoscopic jejunostomy, but what he documented in the note was a diagnostic endoscopy (didn't find anything there) and then he went in via a previously created jejunostomy to look around (and didn't find anything). Can you bill for both of those? If so, which code would you use for the view via the stoma?

No, he cannot use the 45384 if he does not use the "hot" biopsy method. Your doctor must state "hot" biopsy. If they do not and they only state biopsy then it is a 45380. If they did not do a hot biopsy and they want it coded as such then it is fraud.

On the EGD/Jejunum subject, no, you can't code both. You would only code the 44360, "small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)".

That code includes the upper GI tract of the esophagus, stomach and duodenum.
Just curious...what if he had only done the procedure through the stoma? Then what code would you bill?