Review CPT Codes for Colonoscopy with Biopsy, Polypectomy, APC to find out more about the procedures and costs of colonoscopy with biopsy, polypectomy, and/or APC.

CPT Codes are an American coding system that is used to give codes to medical services and procedures. CPT Codes were created and published by American Medical Association in 1966 and have been managed by CPT Editorial Panel ever since.

Whenever some CPT Codes changes are proposed, Editorial Panel review the proposals and approve them annually. CPT Codes are an important system for communicating medical services and procedures among patients, health insurance companies, and health personnel such as doctors, nurses, lab technicians, hospital administrators. By using CPT Codes, miscommunication about medical services and procedures is minimized.

One of the medical services that is important to have CPT Codes is colonoscopy since biopsy, polypectomy, and/or APC can be carried out accompanying the colonoscopy performed.

To put it simply, colonoscopy is a procedure that is performed to see the inside of colon or large intestine and rectum by using a long, thin, and flexible tube with a tiny video camera and a tiny lightning at the end of the tube called a colonoscope or only a scope. The length of colonoscope is around 1200 - 1500 mm (47.3 - 59 inches) that enables the doctor to examine the inside walls of the entire length of the colon. There is a side channel inside the colonoscope that enables the physician to put another instrument in to perform biopsy, polypectomy or APC during colonoscopy.
CPT Codes for Colonoscopy with Biopsy, Polypectomy, APC

To get the best result of colonoscopy, the colon should be empty and clean. To achieve this, patient might be instructed to follow a specific diet instruction several days before the day the colonoscopy is performed. For example, the patient is instructed to do liquid diet for several days before the colonoscopy day. Liquid diet means consuming mostly or only liquids in the form of fruit or vegetable juices or shakes. In addition, the patient might be asked to drink a lot of special solution to clean the colon. Also, laxatives or enema may also be administered to the patient before colonoscopy to clean the colon.

CPT Codes for Colonoscopy with Biopsy, Polypectomy, APC

More than two million colonoscopies are performed each year in the United States. Most of Colonoscopies are performed on outpatient for screening, diagnostic or therapeutic purposes. Colonoscopy Coding can be challenging, especially those procedures that include biopsy and polyp removal. Accurate assignment of colonoscopy procedure codes depends on the documentation of the procedure performed and the technique used to perform the procedure.

Colonoscopy Coding Factors

Different CPT Codes for Colonoscopy with Biopsy, Polypectomy, APC are used. Let's understand how to Code Colonoscopies:
  1. Was other Procedure(s) performed during the diagnostic colonoscopy?
  2. What was the technique used?
  3. What instruments were used?
Once the above factors are determined, use the following information as guidance to determine when each of the following codes is reported:

CPT 45378 Diagnostic Colonoscopies

CPT 45378, Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression is used to report diagnostic colonoscopies.

All surgical colonoscopy codes include a diagnostic colonoscopy. Therefore, if any other procedure but a brushing or washing is performed during the diagnostic colonoscopy, the surgical colonoscopy should be billed using codes 45380-45385. It would not be appropriate to report code 45378 in addition to the therapeutic procedure.

HCPC G0105, G0121 Colonoscopy for Colorectal Cancer Screening

Effective January, 1, 1998, Medicare created HCPCS Level II codes which are equivalent to and are used in place of CPT code 45378 when reporting outpatient colonoscopies for screening of colorectal cancer on Medicare patients.

Code G0105 to report a screening colonoscopy for patients who are at high risk for colorectal cancer. High risk is an individual with one or more of the following: close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp, family history of familial adenomatous polyposis, a family history of hereditary nonpolyposis colorectal cancer, a personal history of adenomatous polyps, a personal history of colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

Code G0121 is used to report colonoscopies for colorectal screening on patients not meeting criteria for high risk. If an abnormality is found during a screening colonoscopy that results in a therapeutic procedure (e.g., biopsy, polypectomy, excision of lesion), then the appropriate CPT code is used instead of HCPCS Level II codes G0105 or G0121.

There various procedures of colonoscopy cause the existence of several different CPT Codes for Colonoscopy with Biopsy, Polypectomy, APC.

CPT Code 45380 Colonoscopy with Biopsy

45380 is Colonoscopy with biopsy, single or multiple. Describes the use of forceps to grasp and remove a small piece of tissue without the application of cautery. The procedure note may describe the biopsy using cold biopsy forceps, or may not mention the device at all.

The biopsy may be from an obvious lesion that is too large to remove, from a suspicious area of abnormal mucosa, or from a lesion or polyp so small that it can be completely removed during the performance of the biopsy.

Colonoscopy with removal by snare technique (45385) should not be used for the removal of a small polyp by “biopsy” or “cold forceps” technique. All lesions or polyps removed by cold biopsy foceps are reported using code 45380.

CPT Code 45381 Colonoscopy with Substance Injection

CPT 45381 is Colonoscopy, flexible, proximal to the splenic flexure; with directed submucosal injection(s), any substance.

Reported when any substance is injected into the submucosal. Substances include saline, India ink, methylene blue, Botox and steroids. For example, code 45381 would be reported for an injection to “tattoo” an area with India ink for later identification during a subsequent procedure.

Code 45381 should be reported as an additional service to any other therapuetic procedure performed at the same time. yet, it is not used to report injections to control bleeding.

CPT Code 45382 Colonoscopy with APC

CPT 45382 is Colonoscopy, flexible, proximal to the splenic flexure; with control of bleeding, (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator).

It is used to describe injection to control bleeding resulting from a number of causes including diverticulosis, angiodysplasia or prior session intervensions.

Bleeding that starts as a result of an intervention performed during the colonoscopy, such as a polypectomy or biopsy, and is controlled by any method is considered part of the initial therapeutic procedure and should not be reported separately with code 45382.

CPT Code 45383 Ablation of Tumor, Polyp

CPT 45383 is 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.

The description of this code is not as clear cut. It can be misleading because it only indicates what techniques the code should not be reported for. Hot biopsy and bipolar cautery techniques are reported with CPT 43584. Snare technique is reported with CPT 43585.

CPT 45383 can be reported for the ablation of a tumor, polyp or other lesion (including arteriovenous malformations) using a number of different devices including heater probe, bipolar cautery prober, or argon laser, argon plasma coagulators (APC).

This is the most often used technique for performing a polypectomy during a colonoscopy. When the snare cautery technique is used, a wire loop is heated and then placed around the desired piece of tissue or polyp to shave off the polyp or lesion. It’s important to note that the snare device may be used with or without heat or cautery. The key term in using this code is “snare” removal. Hot snare, cold snare, monopolar snare and bipolar snare should all be reported with code 45385.

CPT Code 45384 Colonoscopy with Polypectomy

CPT 45384 is 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. This code is used when bipolar cautery and monopolary cautery forceps are used to remove tissue.

Hot biopsy forceps, also called monopolar cautery forceps, create heat in the metal portion of the forceps cup by causing current to flow from the device to a grounding pad on the patient’s body to cauterize the lesion or polyp. Bipolar cautery uses current that runs from one portion of the tip of the cautery device to another to cauterize and remove a lesion or polyp.

If the biopsy and polypectomy are performed on different sites, CPT Code 45380 for the biospy and 45385 (by snare). Thus, CPT code 45380 is used for polypectomy done by cold biopsy and CPT code 45384 is used for hot biopsy for the polyp removal.

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