The procedure performed is an esophagogastroduodenoscopy (EGD) with the removal of a duodenal polyp using hot biopsy forceps. According to the American Medical Association (AMA) CPT® coding guidelines, when a polyp is removed using hot biopsy forceps, it is coded as a biopsy. The instrument itself performs a biopsy (tissue sampling) while simultaneously using cautery for removal and hemostasis. Therefore, CPT® code 43250, Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple, is the correct code to report for this service.

A. 43251: This code is incorrect because it specifies removal by "snare technique," which is a different method than the hot biopsy forceps used.

C. 43255: This code is for controlling active bleeding. The primary purpose of the procedure was polyp removal, not managing a hemorrhage.

D. 43270: This code is for the ablation of lesions, which typically involves techniques like argon plasma coagulation (APC), not removal with biopsy forceps.

1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Section: Digestive System

Endoscopy

Esophagogastroduodenoscopy (Codes 43235-43270).

Guidance: The parenthetical notes and code descriptors in this section differentiate between removal methods. The description for 43250 (with biopsy) is the accepted code for removal via hot biopsy forceps

as distinguished from snare removal (43251) or ablation (43270).

2. AAPC. (2023). 2024 CPC® Official Study Guide.

Chapter: Digestive System.

Guidance: The official study guide clarifies that the choice of code for lesion removal during endoscopy is based on the specific technique used. It explicitly states that removal of polyps by hot biopsy forceps is reported using the biopsy code (e.g.

43250 for an EGD).