Resolved Colonoscopy with Multiple Techniques on One Polyp, Other Techniques Used During Same Procedure

[EmilyM_67452]

Hello. I have a question and hoping someone can help out, If a Colonoscopy w/ polypectomy in transverse colon was performed using both cold snare and cold biopsy forceps, since the cold biopsy forceps was lastly utilized for completely removing the polyp (and not the cold snare)would this is separately billable with mod 59 (45380-59), a separate polypectomy was also performed in the sigmoid colon using hot snare technique. Two techniques were performed at two different sites for different polyps. Would proper coding be 45385 and 45380-59 in this case, or would you only code this as 45385? I remember reading somewhere that if there is the same technique performed (snare in this case) on a separate lesion that you could bill the biopsy technique (where the lesion was removed using both snare and biopsy). I could not find the article where I read this before, and unfortunately really need to have some help with clarification on this. If anyone has any information regarding this or their thoughts they would like to add I would greatly appreciate it. Thanks in advance for your help.

 

[Alicia]

When doing lesion removals in the colon here are the things to note:
1. Where is it
a. More then one in a specific area is listed together
b. Different techniques are listed separately
c. Code Technique that removed lesion when more then one is used
45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45380 - Colonoscopy, flexible; with biopsy, single or multiple
This was a pretty interesting site. Note in the comments a question like yours on May 25th.

Tips & Expertise: CPT for GI Endoscopy Procedures

www.thehaugengroup.com

Jenny on May 24, 2021 at 3:17 pm
If biopsy is taken and a polyp is removed by cold biopsy forceps in a different lesion, can I bill 45380 twice(one for biopsy and one for a polyp removal)?
Reply

• kkluglein on May 25, 2021 at 9:24 am
  Hi Jenny, We passed this along to our training team. Their response was: The CPT for cold biopsy states single or multiple so you would not be able to report it more than once. In order to capture another lesion, it would need to be done by a different technique.

 

[EmilyM_67452]

Thank you so much for your reply and information Alicia!