General Surgery Coding Alert

Question: Using an endoscope, the surgeon "maneuvered an endoloop in the gastric antrum over the stalk of a single 20 mm pedunculated polyp, closed the loop at the mucosal attachment, and removed the polyp." What code describes this procedure?

Montana Subscriber

Answer: Code the procedure as 43251 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). An endoloop is a detachable snare device used for hemostasis during procedures such as endoscopic polyp removal. Because the endoloop uses "snare technique," 43251 is the correct code During polyp removal, surgeons control bleeding by various means such as cautery (thermal coagulation), cryotherapy, or mechanical tamponade. The polypectomy procedure includes bleeding control, so CPT provides different codes based on the hemostasis technique.

For instance: The surgeon might have used hot forceps or bipolar cautery for bleeding control, in which case you should code the procedure as 43250 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

-- Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.