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Thread: Colonoscopy w/multiple technique polyp removal

  1. #1

    Default Colonoscopy w/multiple technique polyp removal

    AAPC: Back to School
    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
    Join Date
    Apr 2007


    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
    Join Date
    Apr 2007


    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. #4


    Thanks for the guidance. I appreciate the help.

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