General Surgery Coding Alert

Question: As part of a colonoscopy, the surgeon noted internal hemorrhoids, which he ablated using hot biopsy forceps, and a raised sessile diminutive polyp in the sigmoid colon. What procedure code(s) should we use?

New York Subscriber

Answer: The answer to your question depends on whether any of the diminutive polyp was removed for pathology analysis, and if so, by what method.

If the surgeon used the hot biopsy forceps to ablate the hemorrhoids and take the polyp biopsy, then you should report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). You would also apply this code when the surgeon uses either monopolar hot biopsy forceps or bipolar cautery forceps.

However, if the polyp was not amenable to removal, then you should code using 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Coding tip: When reporting diagnostic colonoscopy procedures, you should consider a number of factors to guide your code selection:

• Was another procedure(s) performed during the diagnostic colonoscopy?
• If so, what was the procedure(s)?
• What technique was used?
• Was the lesion removed for pathology analysis?
• What instruments were used?