Clinical Documentation: Connecting the Dots | Join Webinar & Earn 1 AAPC® CEURegister Now >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Multiple polyp removals during one encounter

Catherine Posted Sat 10th of December, 2011 03:25:27 AM

Do youfollow the common rule of different techniques in different areas of colon when billing for facility? E.g. 45385 in ascending colon and 45380 in transverse. Otr would you bill for 45385 and 45380 performed in descending.

SuperCoder Answered Mon 12th of December, 2011 05:10:02 AM

45385: Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45380: Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
To code polyp removal scenario correctly you need to consider these three factors:

-how much of the polyp is removed
-the technique used
=whether the tissue fits the definition of “polyp.”
Clue In to Technique
Unfortunately, nothing in CPT’s description of the 45380 or 45385 colonoscopy codes mentions “cold forceps” or distinguishes between removal of whole and partial polyps. So when gastroenterologists use endoscopic instruments, make sure they document which tools they placed on the end of the instrument, because those tools signal the technique they used. For example, when performing a cold biopsy, the physician uses a biopsy forceps not a snare so you’d code this as 45380. I don’t feel comfortable using 45385 when snare technique is not applied.
On the other hand the advice in a 1996 CPT Assistant still holds: If the physician uses cold biopsy forceps to remove a portion of a polyp, you should use 45380. If the physician removes the entire polyp, even without a snare, use 45385. Published by the AMA, CPT Assistant says the code you use should depend on the “actual technique employed” when removing a polyp via a cold biopsy.
Some experts have recommended using 45380 for a cold forceps biopsy and using the snare code (45385) for a cold or hot snare.

Catherine Posted Tue 13th of December, 2011 12:42:32 PM

Thank you. I understand the difference between using which tecniques, but I was wondering if facilities bill for these different techniques when two polyps are next to each other. Or do they at least make sure the polyps are in different areas of the colon.

Related Topics