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Thread: Incomplete colonoscopy w/bx, snare, forceps & injection

  1. #1

    Question Incomplete colonoscopy w/bx, snare, forceps & injection

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    "There was a near obstructing mass at 20 cm in the proximal rectum that could not be passed with the scope. There were 2 polyps at 17 cm. One was a little larger and pedunculated and was removed with snare. The other one was smaller and sessile and removed with biopsy forceps. They were sent together to pathology. There was another polyp at 10 cm which was removed with snare and sent to pathology separate. There were multiple biopsies taken of the rectal mass which were also sent to pathology. Submucosal injection of SPOT was performed. That was placed approximately 5 cm distal to the tumor."

    I've never encountered this before. Am I way off?

    Incomplete scope w/bx 45380 -53
    Polypectomy w/forceps 45384 -53? -59
    Polypectomy w/snare 45385 -53? -59
    Submucosal Injection 45381 -59

    Thanks for your help!

  2. #2
    Join Date
    Apr 2007
    Charlotte, NC


    Can't use the 45380 and the 45384. The biopsies were done in the same anatomical site as the snare (which has the higher RVU).

    I would code it like this:

    45385 (52)

    You would use the snare because it has the higher RVU and you don't need a 59 for the injection (or at least you shouldn't). The modifier for the snare can be debated I guess. Did the doctor know going in that he/she wanted to do a full scope? Did they know there was an obstructing mass in the rectum? If they did then it would be a flex sig not a colon. If they didn't and they expecte4d to do the full colon then you would use the 52 for reduced services not a discontinued procedure (due to poor prep or combative patient, etc).

  3. #3
    Join Date
    Apr 2007


    I believe that 45380 can be used for the rectal mass. I have read this over and over but I may have missed something because you dont state "cold" biopsy or even "hot" biopsy - just snare. If you truly just did everything with snare then yes only 45385 and 45381 can be used but if you did a "cold" biopsy for the mass then 45380 would be appropriate.
    Last edited by scorrado; 01-09-2012 at 08:54 AM.
    Susie Corrado, CPC
    ENT Coding/Billing

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