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45380 or 45388

Tracie Posted Mon 11th of February, 2019 15:33:23 PM
I have a physician who frequently removes colon polyps with cold biopsy forceps, but documents that they are ablated. I am submitting a partial operative report to try to get some clarification on which code should be billed. Thanks for your help. A well lubricated colonoscope was gently inserted per rectum, air was insufflated and scope was advanced up the rectum, navigated throughout the rectosigmoid colon, up the descending colon, across the transverse colon and then dropped down into the cecum. the appendiceal orifice and ileocecal valve were indentified as landmarks. The terminal ileum was briefly intubated and this too appears normal. The scope was then gently withdrawn reexamining the bowel in a 360 degree circumferential fashion. There were no masses, lesions, arterial venous malformation, mucosal inflammation. There was, however, scattered minimal small mouthed open diverticular disease involving all portions of the colon. The scope was withdrawn. Within the sigmoid colon there was a diminutive 5mm semipedunculated polyp. This was affectively ablated with cold forceps technique. Hemostasis was assured. The scope was continuously withdrawn and retroflexed demonstrating the enlarged internal hemorrhoids and several small 1mm flat polyps that are affectively ablated with cold forceps technique. These are ablated and sent to pathology. They are not merely biopsied which would leave portions of the polyp to lead for future neoplasia.
SuperCoder Answered Tue 12th of February, 2019 02:38:41 AM

Hi Tracie,


The consensus among most coders is that when the provider uses a technique other than snare or hot biopsy forceps, such as cold forceps, you should report code 45380 (Colonoscopy, flexible; with biopsy, single or multiple). However, a January 2004 CPT® Assistant article seems to state otherwise:


  • “CPT® code 45380 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.”


While some coders use this CPT® Assistant article to argue in favor of the use of code 45380 to report polypectomies using a cold forceps technique, the answer seems to be ambiguous, at best. While the American Medical Association (AMA) states that 45380 does not describe a specific technique, it further goes on to explain that 45380 typically involves the removal and biopsy of a “small” piece of tissue. Still, 45380 appears to be the “best” option available, despite its shortcomings. However, you also may consider the option of applying code 45399 (Unlisted procedure, colon). It is advised that you contact the payer to confirm that the operative report warrants submission of either code 45380 or 45399.


Please find below SuperCoder article for more understanding on the topic:


Hope, provided information would be helpful.



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