CPT codes: Technique Drives Your Code Selection

When our GI saw a patient for endoscopic biopsy, the patient's mucosa was normal except for internal hemorrhoids and a raised sessile diminutive polyp in the sigmoid colon that was ablated through hot biopsy forceps. In this situation, what CPT codes should be used to describe this procedure?

Be it cold biopsy forceps, hot biopsy forceps or snare technique normally it's the technique that drives your code selection.

Normally the technique should drive your code selection. But then it's possible to ablate a polyp or lesion not amenable to removal with many different devices including all of the above techniques in addition to argon plasma coagulation, gold probe bipolar cautery, and other methods. The answer to this question depends on whether any of the diminutive polyp was removed for pathology analysis.

Removing a specimen means you should code the hot biopsy using 45384, which describes a procedure wherein the physician uses bipolar forceps to both remove and cauterize a polyp simultaneously. You would also use this code when the physician uses either monopolar hot biopsy forceps or bipolar cautery forceps. But then if the polyp was not amenable to removal then you should code using 45383.

Note: The instrument utilized in a colonoscopy is a flexible, thin tube with a video camera and light at the end called a colonoscope. Oftentimes the physician passes other instruments (say for instance biopsy forceps) through the colonoscope to carry out procedures such as tissue biopsy and polypectomy. Many other CPT codes pertain to colonoscopy procedures apart from 45384.

Here are a number of factors you should think about while coding for colonoscopy:

During the diagnostic colonoscopy was another procedure(s) carried out. If it was carried out what was the procedure (s) and what was the technique used. Also consider whether the lesion was removed for pathology analysis as well as what instruments were used.