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Gastroenterology Coding Alert

Reader Question:

Pair of ICD-9 Codes Proves Colonoscopy Necessity

Published on Fri Nov 05, 2004

Question: A patient complaining of rectal pain reported to the office. The gastroenterologist performed a colonoscopy and found two bleeding polyps in the ileum, which she cauterized. Which CPT code should I use to report the procedure?

Idaho Subscriber Answer: For the colonoscopy, you should report 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]).

Don't forget: You should also attach ICD-9 codes 569.42 (Other specified disorders of rectum and anus; anal or rectal pain) AND 211.2 (Benign neoplasm of other parts of digestive system; duodenum, jejunum, and ileum) to 45382 to prove medical necessity.
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