cleegray
New
I am getting mixed opinions for which CPT code to use in this case, I would use 45388, because of the description in the findings, but others say 45384 because he mentions, treated with bipolar cautery.
Does anyone have any concrete evidence of which CPT code would be correct? and what is the difference between removal and ablation of a polyp?
Thank you
Cindy
The colonoscope was introduced through the anus and advanced to the terminal ileum. The colonoscopy was technically difficult and complex due to excessive bleeding. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Attending Participation: I personally performed the entire procedure.
Complications: No immediate complications
Findings:
Impression:
Modifier 22 Addendum:
Does anyone have any concrete evidence of which CPT code would be correct? and what is the difference between removal and ablation of a polyp?
Thank you
Cindy
The colonoscope was introduced through the anus and advanced to the terminal ileum. The colonoscopy was technically difficult and complex due to excessive bleeding. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Attending Participation: I personally performed the entire procedure.
Complications: No immediate complications
Findings:
- The perianal and digital rectal examinations were normal.
- Non-bleeding internal hemorrhoids were found. The hemorrhoids were small.
- Multiple small and large-mouthed diverticula were found in the sigmoid colon.
- Red blood was found in the entire colon. Fluid aspiration was performed.
- The terminal ileum contained red blood.
- A 1 mm polyp was found in the ascending colon. The polyp was sessile. Fulguration to ablate the lesion by bipolar probe was successful.
Impression:
- Non-bleeding internal hemorrhoids.
- Diverticulosis in the sigmoid colon.
- Blood in the entire examined colon. Fluid aspiration performed.
- Blood in the terminal ileum.
- One 1 mm polyp in the ascending colon. Treated with bipolar cautery.
- The colon was cleaned thoroughly, and no obvious source of bleeding could be found.
- At the end of the procedure, bleeding has stopped.
- There was blood in the TI, pointing towards a potential upper GI source.
- There was blood in the NG suction bottle.
- Although the patient had a normal EGD a few days ago, I would like to repeat it.
- Tomorrow EGD.
- Tagged RBC scan
Modifier 22 Addendum:
- This was a very difficult procedure done in the ICU in a critical ill patient.
- There was a large amount of blood in the colon which required suctioning and the colon maneuver was very difficult, due to significant looping and tortuosity.
- All in all, the colonoscopy took significantly longer time than expected.