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EMR

Heidi Posted Wed 01st of March, 2017 09:55:54 AM
with the CPT code 45390 I know its a lift and technique that is required but can you tell me if the only technique includes snare and hot biopsy or does cold biopsy inclueded
SuperCoder Answered Thu 02nd of March, 2017 08:02:40 AM

CPT code 45390 (Colonoscopy, flexible; with endoscopic mucosal resection), so we would like have  some more detail of the procedure note as well as diagnosis to help you with appropriate code.  

Heidi Posted Thu 02nd of March, 2017 11:20:39 AM
the reports states the polyp was dificult to see even and was brought into better view with a saline lift and removed with cold forcepts area was successfully injected with saline for a lift polypectomy and polyp was removed with cold biospy
SuperCoder Answered Fri 03rd of March, 2017 01:05:21 AM

Colonoscopy procedures performed involving biopsies and/or the removal of a polyp using the cold biopsy forceps method, bill the 45380 CPT code.

NOTE: If the physician performing a colonoscopy attempts — but fails — to remove a polyp by snare technique, but he/she is successful at removing the polyp via another technique (such as cold biopsy forceps), only bill the CPT code for the technique/procedure which was successful (use code 45380 for a cold biopsy forceps polypectomy in this case).

Heidi Posted Fri 03rd of March, 2017 10:28:13 AM
What we are trying to figure out is can an EMR be billed if the physicians says, "uses saline injection to raise a lesion or polyp and then removes it by BIOPSY." Can this be billed as 45390 or does it need to be billed as 45380 and 45381-59 becuase they're using BIOPSY to remove is versus Snare or Hot biopsy.
SuperCoder Answered Mon 06th of March, 2017 08:29:12 AM

As per the coding guidelines CPT 45380 cannot be billed in conjunction with 45390. Also, the work done under CPT 45390 (i.e. use of saline injection to raise the lesion or polyp) was on the same polyp and in the same session, hence, it would be considered inclusive in the final technique of polyp removal (i.e. cold biopsy).

According to CPT coding guidelines for colonoscopy, it is not the number of polyps removed, but the different techniques used to remove the polyps. In your scenario polyp was removed via cold biopsy, therefore, CPT 45380 is the appropriate code.

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