Learn How to Bill a Deferred Polypectomy
Question: A patient with APC I1307K had a screening colonoscopy in October 2025. The provider decided that the patient shouldn’t have desmopressin prior to the procedure, but the physician informed the patient that they would have to return at a later date to redo the procedure with desmopressin if anything was found during the examination. The gastroenterologist found a 5 mm polyp in the sigmoid colon during the colonoscopy, but the provider didn’t remove it because the patient needed to be on desmopressin. The patient, having taken desmopressin, returned in February 2026 to repeat the colonoscopy for the polypectomy. How should we bill the February colonoscopy? Connecticut Subscriber Answer: Assign 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) to report the colonoscopy that the provider performed in February 2026. Yes, the gastroenterologist performed another colonoscopy in February, but it is not a repeat of the screening colonoscopy from October 2025. The intent behind the February colonoscopy was therapeutic — to remove the polyp found during the screening. Important: The documentation should include the different body structures reached and visualized to report the colonoscopy code. According to the CPT® guidelines, if the physician advances past the splenic flexure but cannot reach the cecum, you’ll append modifier 52 (Reduced services) to the procedure code. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
