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Incomplete polypectomy

  1. #1
    Default Incomplete polypectomy
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    Doctor was unable to remove entire polyp during colonoscopy. He did an india ink tatoo of the area for a possible follow up colonscopy to remove the rest of the polyp. My question is, would the first colonoscopy be considered incomplete? Opinions and or references to any material addressing this would be appreciated.

  2. #2
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    Did your physician remove a portion of the polyp? Sometimes there is "piecemeal" removal using a snare which would be coded with 45385 and the marking of the polyp is coded with the submucosal injection, 45381 (if a colonoscopy beyond the splenic flexure was performed).
    Jenny Berkshire, CPC, CEMC, CGIC

  3. #3
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    It doesn't look like incomplete. But you may want to use -52 just to be on the safeside. Any ideas ??

  4. #4
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    Quote Originally Posted by coderguy1939 View Post
    Doctor was unable to remove entire polyp during colonoscopy. He did an india ink tatoo of the area for a possible follow up colonscopy to remove the rest of the polyp. My question is, would the first colonoscopy be considered incomplete? Opinions and or references to any material addressing this would be appreciated.
    As long as tissue was taken and biopsied it is a complete biopsy, if the cecum was not ever reached then it would be considered incomplete.
    Mary, CPC, CANPC, COSC

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