Colonoscopy with Biopsy and Polypectomy Procedures Coding in CPT

Coding colonoscopies with multiple biopsies and polypectomies can be confusing, especially for a new coder. In this coding tip, we will look at the rules that govern coding these different techniques.

Coding colonoscopies with multiple biopsies, polypectomies, and/or different techniques requires using appropriate CPT codes and modifiers. A colonoscopy can be performed through a stoma rather than the anus and would follow the same reporting guidelines as a regular colonoscopy.

The following CPT codes are utilized for colonoscopy alone and colonoscopy with biopsy, polypectomy and can be found in the CPT book listed in the digestive section. Keep in mind there are other colonoscopy procedures other than biopsy and polypectomy.

45378: Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

45380: Colonoscopy, flexible, with biopsy, single or multiple (cold biopsy forceps)

45384: Colonoscopy, flexible, with removal of tumor(s), polyp(s) or other lesion(s) by hot biopsy forceps

45385: Colonoscopy, flexible, with removal of tumor(s), polyp(s) or other lesion(s) by snare technique

44389: Colonoscopy through stoma with biopsy, single or multiple

44392: Colonoscopy through stoma with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

44394: Colonoscopy through stoma with removal of tumor(s), polyp(s) or other lesion(s) by snare technique

44401: Colonoscopy through stoma with ablation of tumor(s), polyp(s), or other lesion(s)

Guidelines:

1. If multiple lesions or polyps are removed by the same technique, report the code only once. For example, if three separate polyps are removed by the snare technique you would code 45385 only once.
2. When two separate lesions or polyps are removed by different techniques you can report both codes for the separate techniques. For example, one lesion/polyp is removed by hot biopsy forceps (45384) and one lesion/polyp is removed by the snare technique (45385) you would code 45384-59/XS and 45385. The modifier on the 45384 is needed to delineate that they are two separate lesions being treated.
3. When a biopsy is performed on a lesion/polyp and then the same lesion/polyp is removed during the same operative session you would only report the removal of that lesion. For example, a biopsy is done of a lesion (45380) and then following the biopsy it is removed by the snare technique (45385). You would code the snare technique only 45385.

Coders need to carefully review the entire procedure note to identify how many separate lesions are being treated and how many separate techniques are being used to be able to have accurate coding for these colonoscopy procedures.

References

CPT Assistant, August 2021 Page 15

CPT Assistant, April 2011 Page 12

CPT Assistant, October 2001 Page 4

CPT Assistant, February 1999 Page 11

CPT Assistant, July 1998 Page 10

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.