Wiki Colonoscopy with Polyp Removal


Chillicothe, Texas
Best answers
:confused: I can't decide how best to code this colonoscopy:

Multiple diverticula were found in the sigmoid colon. A large flat polyp
was found in the cecum. The polyp was ~20 mm in size and had poorly
defined margins. There was a focal area of fibrosis at the margin of the
polyp, likely related to previous biopsy. The submucosa below the polyp
was injected with saline mixed with indigo carmine for a lift
polypectomy. The polyp was removed with a piecemeal technique using a
hot snare. Polyp resection was incomplete, due to inability to ensnare a
very flat portion of the polyp. Numerous attempts were made, using
several different types of snares. The resected tissue was retrieved.
Coagulation for destruction of remaining portion of lesion using argon
plasma was performed.

I know 45381, 45383, & 45385 are all used for removal of this polyp, but I don't think I can code for all of them on a single polyp. Any suggestions would be greatly appreciated!


Tracy F, CPC, CPC-H