Kevinph84
Guest
My Fellow Coders,
I had a patient come in for removal of a rectal lesion. The lesion was grasped, excised, and a suture was placed. The approach was through the anus.
The path report delivered a diagnosis of "Polypoid fragment of squamous epithelium and underlying fibrovascular tissue. The differential includes hemorrhoid. Negative for dysplasia or malignancy. Negative for condyloma."
I was searching through CPT and found the following code a as a good candidate:
45171
Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness)
Lay Description
The physician removes a rectal tumor through a transanal approach. The physician explores the anal canal and exposes the tumor. Report 45171 for a partial thickness excision (one that excludes the muscularis propria) and 45172 for a full thickness excision (including the muscularis propria). The defect in the rectum is closed with sutures.
Now, the only conflicting issue I have is the diagnosis basically being lesion of the rectum, as oppose to the CPT code stating tumor.
My question is if the code says tumor and the patient has a lesion, in which the same exact procedure was performed, is it still applicable to use that procedure code?
Thank you all for your help!
Respectfully Yours,
I had a patient come in for removal of a rectal lesion. The lesion was grasped, excised, and a suture was placed. The approach was through the anus.
The path report delivered a diagnosis of "Polypoid fragment of squamous epithelium and underlying fibrovascular tissue. The differential includes hemorrhoid. Negative for dysplasia or malignancy. Negative for condyloma."
I was searching through CPT and found the following code a as a good candidate:
45171
Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness)
Lay Description
The physician removes a rectal tumor through a transanal approach. The physician explores the anal canal and exposes the tumor. Report 45171 for a partial thickness excision (one that excludes the muscularis propria) and 45172 for a full thickness excision (including the muscularis propria). The defect in the rectum is closed with sutures.
Now, the only conflicting issue I have is the diagnosis basically being lesion of the rectum, as oppose to the CPT code stating tumor.
My question is if the code says tumor and the patient has a lesion, in which the same exact procedure was performed, is it still applicable to use that procedure code?
Thank you all for your help!
Respectfully Yours,
