Wiki Polyp Removal by snare, and ablation

Atillema12

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Hi,

I need advice on a polyp removal. The following shows a polyp removed by snare and also fulguration on that same lesion. I am being advised to code both 45385 for snare and 45388 for ablation. Would both be coded for same location?

A 10 mm polyp was found in the descending colon. The polyp was semi-pedunculated. The polyp was removed with a
saline injection-lift technique using a hot snare. Resection and retrieval were complete. Fulguration to ablate the lesion by
argon plasma was successful. To prevent bleeding after the polypectomy, one hemostatic clip was successfully placed.
There was no bleeding at the end of the procedure.

Any help is appreciated. Thank you
 
Only one code can be reported for this. Its mutually exclusive per NCCI so report the more complex code for more than 1 technique on same polyp.
 
Polyp removal using saline inj-lift technique & snare is 45390

Regarding:
"The polyp was removed with a saline injection-lift technique using a hot snare. Resection and retrieval were complete...."

Just wanted to add that actually this technique fits the definition of CPT 45390 "Colonoscopy, flexible; with endoscopic mucosal resection". :)
 
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