Our facility needs clarification regarding how to correctly assign colonoscopy codes for ablation, destruction, and removal. The CPT code narrative for 45383 states, Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique. However, if a polyp is ablated via hot biopsy forceps or snare, would CPT codes 45384 or 45385 be the correct codes? There does not appear to be CPT codes for ablation.
Yes, it is very important to identify the technique being utilize for the removal of lesions via colonoscopy. The snare technique is reported with CPT code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, and is often utilized to perform a polypectomy during a colonoscopy. Snare devices may also be used without electrocautery to “decapitate” small polyps. Some of the phrases used to identify a snare technique are “hot snare”, “monopolar snare”, “cold snare”, or “bipolar snare”.
Hot biopsy forceps removal of lesions is coded with CPT code 45384, Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. To insure that you are coding accurately the operative or procedure report must be read thoroughly. For more extensive information regarding the appropriate coding of the removal of lesions via colonoscopy, see the AMA’s CPT Assistant, January 2004, page 4.