General Surgery Coding Alert
Nail Down Method and Reason for Colonoscopy Code
Question: Our surgeon documented a colonoscopy for a 62-year-old female patient who had a positive fecal-occult blood test. The surgeon retrieved a 6 mm sessile polyp from the sigmoid colon with hot biopsy forceps. How should we code this? Texas Subscriber Answer: You should report 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps). You should not use 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique), which describes snare technique, not hot biopsy forceps. You should not report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for the case, because the procedure is a diagnostic colonoscopy based on signs and symptoms, not a screening colonoscopy.
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