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Thread: colon biopsy coding

  1. #1

    Default colon biopsy coding

    AAPC: Back to School
    If a physician removes a polyp using cold forceps instead of leaving it and just doing a bx would you still code 45380. One of our doctors is wanting to use 45383.

  2. #2
    Join Date
    Apr 2007

    Default re: cold forceps

    I use the 45380 for cold forceps. This might help clarify a little more:

    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
    Last edited by danastiff; 05-04-2011 at 09:55 AM. Reason: adding additional information

  3. #3


    I'd use 45380....
    45383 is an ablation

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