Wiki Colonoscopy with Snare Polypectomy & Ablation


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Am I right in billing 45385 & 45383-59 for the following operative note? I'm not completely comfortable with this because the note indicates Transverse Polyp removed by ablation and then Descending & Sigmoid Colon polyps removed by snare & ablation. My concern is ablation is mentioned for both areas of the colon so I'm thinking I should bill only 45385.

DESCRIPTION OF PROCEDURE: After discussion with the patient, the risks and benefits of the procedure, informed consent was obtained. Digital rectal examination did not reveal the presence of mass or fistula. The Olympus colonoscope was introduced through the patient's rectum and advanced to the cecum in the usual technique. Cecum was identified by the presence of the ileocecal valve and the appendiceal orifice. The quality of prep was good. Thorough examination of entire mucosa was performed while endoscope was withdrawn.

Normal cecum, normal ileocecal valve, normal ascending colon. Transverse colon with 4.0 mm polyp. Biopsies were taken and destroyed with ablation. Descending colon and sigmoid colon with six polyps, size 4.0 to 6.0 mm's, removed with snare polypectomy and ablation. Mild diverticulosis was seen in sigmoid colon. Rectum on retroflexion with moderate internal hemorrhoids. The colonoscope was completely withdrawn from the patient and the procedure terminated. The patient tolerated the procedure well.

Thanks very much for any input on this.

Your gut feeling is correct. You would only code the ablation (45383).

This is because you can only code the highest level completed for each site and if the highest level completed is ablation then you can only code it once no matter how many times or different colonic areas.

Now if your doctor had done the ablation in the transverse and then done a snare in the descending and not an ablation also, you could charge for both.