endoscopy with forceps

I have a claim that the Dr. did a 43239 & he also removed a polyp with forceps? I was going to use 43250, however I am not positive if it was "hot biopsy forceps" Is there another code I should be using?

Mar 13th, 2012 - rphelps 615 1

re: endoscopy with forceps

43258 for removable other than hot bx or snare.

Mar 13th, 2012 - nmaguire 2,606

re: endoscopy with forceps

As usual, documentation will walk to the appropriate code, no guessing. There are many variations of the upper GI endoscopy and documentation must clearly describe the service. Further, if a lesion is removed, the method (hot biopsy forceps, snare or ablation) should also be indicated in the procedure notes, as well as at the top of the procedure report. Did the physician take a biopsy at one site and remove a polyp from another site (document technique). It is difficult to give an accurate answer with this information.