There were no abnormalities noted except for a 5-mm sessile polyp noted in the proximal transverse colon. A polypectomy was performed with removal using forceps (45380? or 45384?). In the descending colon, a 4-mm polyp was biopsied (45380). Further withdrawal of the scope revealed internal hemorrhoids. The scope was then withdrawn. The patient was then transferred to the Recovery Room in a stable condition.
Physician query is indicated since the technique of the polyp removal is not detailed in the operative report. If the physician performed a cold biopsy forceps removal, only CPT 45380 is reported. If the physician performed a hot biopsy forceps removal (CPT 45384), then a total of two different techniques were performed on two separate polyps and both may be reported.
- If determined that a cold biopsy forceps technique was performed in the transverse colon, report CPT 45380 only once for the entire colonoscopy case. Both cold biopsy forceps technique performed in the transvers colon and the biopsied polyp in the descending colon are reported with the same CPT code 45380.
Correct code: (CPT 45380 = $380.23 approximate Medicare reimbursement)
- If determined that a hot biopsy forceps technique was performed in the transverse colon, report CPT 45384 in addition to the technique used for the biopsied polyp that was biopsied in the descending colon (CPT 45380).
Correct code: (CPT 45384 = $380.23; CPT 45380-59 = $380.23/2 approximate Medicare reimbursement)
Coding tip: If the physician performs and describes a colonoscopy with “biopsy” of a polyp, a query would not be necessary since CPT code 45380 indicates a colonoscopy with biopsy.
Cristina Bentin can be reached at cristina@ccmpro.com. Learn more about Coding Compliance Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
