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Gastroenterology Coding Alert

You Be the Coder:

Method Overrides Numbers While Reporting Polyp Removal

Published on Mon Mar 12, 2012

Question: Our gastroenterologist recently performed a colonoscopy. The operative report read like this:Multiple small and large-mouthed diverticula were found in the sigmoid colon. Estimated blood loss: none. A pedunculated polyp was found in the sigmoid colon. The polyp was 20 mm in size. The polyp was removed with a hot snare. Resection and retrieval were complete. Estimated blood loss: 25 mL requiring treatment with epinephrine and 4 clips. A sessile polyp was found in the sigmoid colon. The polyp was 4 mm in size. Biopsies were taken with a cold forceps for histology. Estimated blood loss: none. Multiple small (>5mm) polyps were found in sigmoid and rectum that were not biopsied. Non-bleeding internal hemorrhoids were found during retroflexion.Let me know what the correct way of reporting the procedure is.New Jersey SubscriberAnswer: Note that your gastroenterologist used two different procedures to remove the polyps, namely, hot snare and cold biopsy forceps. [...]
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