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Colonoscopy with Polypectomy by Cold Bx Bites

  1. #1
    Default Colonoscopy with Polypectomy by Cold Bx Bites
    Medical Coding Books
    Just wondering how everyone else is coding Colonoscopies
    and Polypectomy by cold bx bites. I have been coding
    this procedure with the 45380 but have recently been told
    by a GI biller she uses the 45383 if the polyp is completely
    removed. Then I read an old CPT assist. that you could use
    a 45385 Any input would help!!! Thank you,Deb, CPC

  2. #2
    45385is Bx by "snare" technique. You are correct with using the 45380 for coold bx. See Coding Clinic articles on polypectomies for back-up confirmation.

  3. #3
    Default polypectomy
    I agree 45380. 45383 is ablation by other method. 45385 is by snare. There's another post on here somewhere concerning this very topic, you might try the search feature for the other discussion/s.

  4. #4
    Greeley, Colorado
    Deb - you are coding these correctly, as previously stated by Anna and Leslie. Per CPT Assistant Jan 2004 Colonoscopy coding made simple:

    Snare devices may also be used without electrocautery to “decapitate” small polyps. Most often the colonoscopy report will specify that a “snare technique” was used. But do not let alternative terminology throw you off. The report may also include the phrase “hot snare,” “monopolar snare,” “cold snare,” or “bipolar snare,” all of which should be reported using code 45385.

    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.
    Lisa Bledsoe, CPC, CPMA

  5. Default Colonoscopy w/ cold biopsy forceps removal
    Just wondering why #45380 is more appropriate than using #45384, or is that code strictly for "hot biopsy forceps removal"? Why does "cold" put it in the #45380 category?
    Thanks, Beth

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