Results 1 to 4 of 4

Colonoscopy w/multiple technique polyp removal

  1. Default Colonoscopy w/multiple technique polyp removal
    Medical Coding Books
    One of my doctors performed a complicated polyp removal during a colonoscopy.

    My understanding is that I can code for one removal technique and the saline lift for the flat polyp.

    I planned to code this as 45385 with 211.3 and 45381-59 dx. 211.3 aqnd line 19 saline lift prox. transverse polyp. Is this the correct coding sequence?

    The OR reports reads as follows:

    “In the proximal transverse colon, we found a very flat polyp; it was occupying the surface of a fold actually on 2 sides. It was approximately 2 cm. We used multiple techniques to try and remove this. I used a mucosectomy technique, raising it up with saline and then using a snare and a piecemeal fashion along with hot biopsies and finally argon ablation to completely ablate down this area. There was no excessive heme afterwards. The remainder of the colon was negative for colon polyps. I did inject spot carbon ink at the site of polypectomy in case it needs to be identified again….”

    Thanks for any advice you can provide.

  2. #2
    You will not need to use the mod 59 with 45381 and I would go with 45383 instead of the snare (45383 - with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique). Anybody else have other suggestions?

  3. #3
    Agreed....NCCI mutually exclusive edits considers 45385 to be a component of 45383, and you do not need a modifier for the 45381. As Jojo states, I would suggest coding as 45383, 45381.
    Last edited by j.berkshire; 03-17-2011 at 06:49 AM. Reason: edit
    Jenny Berkshire, CPC, CEMC, CGIC

  4. Default
    Thanks for the guidance. I appreciate the help.

Similar Threads

  1. Colonoscopy w polyp removal via ablation & snare
    By dyoungberg in forum Gastroenterology
    Replies: 3
    Last Post: 09-14-2012, 02:14 PM
  2. Colonoscopy with Polyp Removal
    By tfrick2 in forum Gastroenterology
    Replies: 5
    Last Post: 08-13-2012, 08:10 PM
  3. Partial Removal of Colon Polyp Snare Technique
    By Shaheedahp in forum Gastroenterology
    Replies: 4
    Last Post: 12-29-2010, 10:40 AM
  4. ASC Colonoscopy with polyp removal seperate technique??
    By bdobyns in forum Outpatient Facilities
    Replies: 5
    Last Post: 11-15-2010, 09:25 AM
  5. Colonoscopy w/polyp removal- path has fecal material
    By TLVANDERPOOL in forum Gastroenterology
    Replies: 1
    Last Post: 09-25-2008, 12:41 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.