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Wiki polyp removed with scissors?

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CaroleF01

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43
Location
Melvin, MI
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How do I code this? It is a polyp removed during a colonoscopy.

"Once I reached the distal rectum a retroflex maneuver was done and showed slightly enlarge hemorrhoid, intact staple line and 1.5 cm polyp just distal to the staple line, hemorrhoid vs polyp. I tried a hot snare for resection but it did not cut through, so I put a clamp at the stalk and cut above it with a scissor and tied the stalk with 2-0 Vicryl. No bleeding noticed after."
 
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Hi
I d use CPT 45382 cold forceps removal. Ensure use the dx of polyp removed from distal rectum descending colon) this as first dx. It is dx. D12.4, then dx. Z12.11 as last dx code. I hope this helps you
Lady T:)
 
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What did path come back as? Sounds like an internal hemorrhoidectomy by ligation to me. The staple line sounds like pt may have had a prior hemorrhoid removal or surgery as well.
 
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Hooray! I would query if hot or cold biopsy.
hot 45384
cold 45380
I disagree with the 45382 as bleeding is a part of the procedure
Happy coding:)
 
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