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polyp removal

Kami Posted Fri 07th of August, 2015 08:31:22 AM

4 diminutive polyps less than 5mm were removed in their entirety by cold biopsy and tissue recovered. Can you use 45385 instead of 45380 since it was a polypectomy?

SuperCoder Answered Fri 07th of August, 2015 15:21:01 PM

Thanks for your question. The difference with these two codes are the removal methods. For procedure code 45380; Colonoscopy, flexible; with biopsy, single or multiple, the provider takes one or more samples of this tissue using biopsy forceps. For 45385; the provider removes one or more tumors, polyps, or other lesions with a snare, a type of surgical instrument with a wire loop that the provider passes around the base of the growth and gradually tightens to remove the lesion. In this scenario, your provider used biopsy forceps and not a snare technique; so your only option would be to code 45380. Hope this helps.

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