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Rectal lesion!!!!!!!!!!!!

  1. #1
    New Port Richey & Gulf to Bay
    Question Rectal lesion!!!!!!!!!!!!
    Medical Coding Books
    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:

    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,

  2. #2
    Green Bay, WI
    I feel it's appropriate to use this CPT. I would appeal any denial.

  3. #3
    Excision of benign lesion; genitalia= 11420 thru 11426
    Amnery Rodriguez, CPC

  4. #4
    Default Rectal Lesion
    I work for a Colorectal surgeon and we run into this quite offen. I use 45171 with Icd.9 211.4, 787.99, or 569.49.

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