Wiki Help with Transrectal excision of large rectal polyp

[Libest]

" First the rigid sigmoidoscopy had been performed. The Dr, could see the polypoid growth in the rectum just above the dentate line. The Dr did a rectal ultrasound, whic confirmed the rectal polyp. After the patient was prepped and drapped, using a bivalve retractor in the rectum, the Dr transrectally removed the rectal polyp down to muscle. The specimen was sent to pathology. Then, Surgicel was placed on top of the wound site. After the procedure, the Dr performed a rigid sigmoidoscopy again, he could not see any remaining polyp"
Do I code the ultrasound 76872, sigmoidoscopy 45300 and excision of rectal tumor 45172?

 

[Amy Pritchett]

You are correct in your coding. However, are you an ASC or private office? The CPT codes you selected are correct. The 45300 for sigmoidoscopy (since diagnostic); 45172 removal of the rectal tumor. However, does your facility allow you to charge the 76872 for the ultrasound portion of the examination? Certain outpatient facilities and ASC's will only allow the department to code for the radiology portion of a procedure. This is due to the fact that the ultrasound is not APC approved for separate billing and will not be paid on the ASC side. If so, then your codes look great and you are ready to go
Hope this helps