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Colonoscopy with snare polypectomy

  1. #1
    Northeast Kansas AAPC
    Question Colonoscopy with snare polypectomy
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    Medicare patient with left lower quadrant pain presents for colonoscopy. There was extensive diverticulosis throughout the sigmoid and left colon. There was a small polyp in the descending colon at 50 cm. This was biopsied with snare polypectomy. It was small enough that the specimen was essentially destroyed by cautery so we retrieved no specimen. The colon was otherwise without evidence of mass, colitis, significant AVM or andiodysplasia. Retroflex did reveal findings consistent with internal hemorrhoids.

    Can I bill a 45385 without a path report for the polyp? If so, do I use diverticulosis and internal hemorrhoid only as diagnosis? Thanks for your help!!!

  2. #2
    I would bill with a 45385 snare polypectomy, the procedure was done, it just did not get biopsied, this does not negate the procedure. You can still code the polyp and diverticulosis. I would not code the hemorrhoids as he says "consistent with".

    Any other takers?
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  3. Smile
    I agree. Bill the 45385 - the snare. And use the polyp and diverticulosis - yep.

  4. #4
    Default Colonoscopy - snare
    I would code snare 45385 with polyp and diverticulosis.
    I wouldn't do the hemorrhoids - incidental to procedure.

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