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45383 versus 45380

  1. #1
    Hyattsville Maryland
    Default 45383 versus 45380
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    I have a heated discussion at the office with regards to the following issue: Physician states in his report that he ablated a polyp with cold forceps. My thinking is that the word ablate means remove, so hy removed the polyp with cold forceps, which makes it a 45380. I would like your thoughts on this, thanks.
    Catherine Du Toit CPC, CPMA, CGIC,
    AAPC Professional

  2. Default
    Since your provider states he is using the cold biopsy forceps, I would use 45380. 45383 states "not amenable to removal by hot biopsy forcepts, bipolar cautery or snare" does that mean we cannot use this code for your situation? Good question.

    I looked up the definition of ablation: The removal of abnormal tissue growths by surgery.

    So ablation with cold biopsy forcepts seems to fit your situation, because the code description does not exclude the cold biopsy forceps.

    However, if he wouldn't have used the term ablation and stated polyp removed by cold biopsy forcepts we would use 45380.

    I'd like to hear others thoughts on this as well.

    Personally, I would use 45380, though.

  3. #3
    The following information is from the 'Gastroenterology Coding Alert Vol 11 2008:

    What is ablation? Ablation usually refers to a cauterization technique the physician performs with an argon plasma coagulator, heater probe, or other device that destroys any remaining polyp cells after a prior colonoscopy in which the surgeon removed a larger polyp using a snare.

    When your gastroenterologist uses any of these methods for an ablation of a non-bleeding angiodysplasia or polyp tissue from a site where tissue was not removed during the same procedure, you should report 45383...

    Watch out: 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 polyp by another method...
    1. If the gastro removes and then ablates with hot biopsy forceps, report 45380 instead.
    2. if uses bipolar cautery for removal followed by ablation, opt for 45384.
    3. you should code snare-technique removal followed by ablations with 45385.

    Hope this helps!

  4. #4
    Hyattsville Maryland
    Default Thank you
    Thank yhou for these responses. I only noticed it now. The site did not let me know that there were responses on my question. It really cleared the way, thanks.
    Catherine Du Toit CPC, CPMA, CGIC,
    AAPC Professional

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