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Colonoscopy w/ polypectomy with cold forceps

  1. Default Colonoscopy w/ polypectomy with cold forceps
    Medical Coding Books
    I'm new to coding for colonoscopies and had a question about polyp removal with cold forceps. I wasn't real clear on which CPT code I should use, I thought either
    45380 or 45383. I would love to hear feedback on this from other coders out there.

  2. #2
    Default colonoscopy
    Personally, I use the 45380 for cold biopsy/polyp removal and for biopsy. I use the 45383 for ablation by any other method. I don't use it very often, just maybe a couple of times, my Doc uses mostly snare and hot biopsy.
    I would like to see what other's do also.

  3. #3
    Greeley, Colorado
    Per CPT Assistant January 2004 in an article "Colonoscopy Coding Made Simple":
    CPT code 45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple, does not describe a specific technique. The terminology is accepted and understood by colonoscopists to mean the use of a forceps to grasp and remove a small piece of tissue without the application of cautery. Colonoscopy reports may describe the biopsy of a lesion or polyp using a cold forceps or may describe the biopsy without mentioning the specific device. The biopsy may be from an obvious lesion that is too large to remove, from a suspicious area of abnormal mucosa, or from a lesion or polyp so small that it can be completely removed during the performance of the biopsy, which is often demonstrated with the cold biopsy forceps technique. The technique is the same and the service is reported with code 45380 regardless of the final histology of the piece of tissue obtained for analysis. Colonoscopy with removal by snare technique, 45385, should not be used for a report describing the removal of a small polyp by “biopsy” or “cold forceps” technique.

    I agree with Anna.
    Hope this helps.
    Lisa Bledsoe, CPC, CPMA

  4. Default
    Thanks Anna and Lisa you were both a great help

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