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Thread: colonoscopy - How would you code this colonoscopy

  1. #1

    Default colonoscopy - How would you code this colonoscopy

    AAPC: Back to School
    How would you code this colonoscopy? After adequate IV conscious sedation a digital rectal examination was performed and found to show a 3 cm pedunculated fibro-epithelial anal polyp. The scope was then inserted in the rectum and advanced under direct visualization throughtout the length of the colon. HE had significant amount of mucous in the distal portion of the colon making visualization somewhat difficult. Cecum was reached and photographed. Scope was the slowly withdrawn paying careful attention to all sidewalls. No abnormalities were noted. Scope was then retroflexed in the rectum. this appeared normal. Post-Procedure Diagnosis: Normal colonscopy and probable fibro-epithelial anal polyp. This was removed with 1% lidocaine and sicissors. Hemostasis achieved with silver nitrate. Do I code a 45378 and a 46230. Please advise. Thanks
    Last edited by ank3t; 10-07-2016 at 05:14 AM.

  2. #2


    I think
    45381 59

    May 2008 CPT assistant it states: "Ablation implies removal or destruction of tissue."

    Unlike the techniques described in codes 45385 and 45384, the terminology used to indicate when code 45383, Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique, should be reported is not as clear cut. The definition of code 45383 can be misleading because it only indicates what techniques the code should not be reported for. The snare technique is reported using code 43585; hot biopsy and bipolar cautery techniques are reported with code 43584. Code 45383 can be reported for the ablation of a tumor, polyp or other lesion including arteriovenous malformations using a number of different devices including heater probe, bipolar cautery probe, or argon laser, argon plasma coagulators (APC).
    Last edited by ASC CODER; 12-29-2009 at 10:21 AM.

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