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Polypectomy with Cold forceps comments GI coders?

1formissy

1formissy

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Location
Albany, OR
Patient has a colonoscopy performed, with removal of a polyp by cold forcep. The medical record does not indicate the polyp was sent for path.

According to the AMA, it states that if a physician removes a polyp by cold forceps, it is coded as 45380.

The problem I am having with this, is CPT says 45380 is "with biopsy, single or multiple."

Any experienced GI coders out there have a an opinion they wish to share with me?

Thanks in advance.
 
I would still code it 45380, a biopsy was performed, sometimes the tissue or polyp is not retrieved but I still code for the biopsy or snare. There just would not be any pathology billing.
 
I also have always coded the 45380. The polypectomy with cold forceps is a method used to remove the abnormal tissue from the colonic mucosa. While retrieval is ideal, it is secondary to the purpose of the procedure.
 
Code from the colonoscopy report. If the provider mentions he/she used cold forceps to biopsy a polyp, then 45380 is supported.

The biopsy should've been sent for pathology. On rare occasions, the tissue is lost, unretrieved, or destroyed when the path lab preps it.
 
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