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Thread: rectal polyp

  1. #1
    Join Date
    Apr 2007
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    Default rectal polyp

    I have look over and over for the cpt code for excision of a retal polyp , closest code I come up with is 46922, not sure if this is right . As it says operative report he used a scalpel to use this, DOC office says to use 45990 which is a anorectal exam with cpt code 46611 by snare technique, which I disagree with their code .Any suggestions? thanks

    OSTOPERATIVE DIAGNOSIS: Rectal polyp.
    OPERATION: Excision of rectal polyp.

    ANESTHESIA: General.
    COMPLICATIONS: None.
    BLOOD LOSS: None.
    PROCEDURE IN DETAIL:
    The patient was taken to the OR and prepped and draped in the usual sterile fashion in lithotomy. Once this was done, rectal exam revealed a polyp on the anterior rectal wall. The polyp was well visualized. Using the Harmonic scalpel, it was removed in its entirety, across its well defined pedunculated stalk. This left a small defect. The defect was closed with two 3-0 Vicryl interrupted sutures. There was excellent hemostasis in the area. All needle and sponge counts were correct. Specimen was sent to Pathology for permanent section.

  2. #2

    Default

    45108?

    desk reference:

    The physician removes a muscle tumor or a section of muscle from the anorectum The physician identifies the anorectal muscle tumor or area of interest. A transanal incision is made through the rectal wall and the tumor or identified are of muscle is excised. The incision is closed by approximating the muscle edges and closing the incision in the rectal lining.

    If that is not what the doc did then I would use unlisted.

    hope this helps
    LG CPC,CASCC

  3. #3
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    Apr 2007
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    Default

    thanks asc code but I'm not sure if poylp isconsidered a tumor ?

  4. #4
    Join Date
    Apr 2007
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    Default

    thanks asc code but I'm not sure if poylp is considered a tumor ?

  5. #5

    Default

    There is 45108 AnoRECTAL myomectomy myomatous POLYP = a POLYP that consists of benign neoplastic tissue derived from nonstriated (smooth) muscle. SYNONYM - fleshy POLYP If that does not then probably unlisted

    The term TUMOR and POLYP vs lesion vs mass are at times used as the same 45171Excision of rectal TUMOR, transanal approach

    Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness) etc...

    anyway,

    Here are some ideas
    LG CPC,CASCC

  6. #6

    Default APV Coder

    2017 ICD-10-CM Coding Book
    If the procedure is excision code 45171. If edoscopically; polyp,tumor or lesion removed, code 45308.

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