tci General Surgery Coding Alert - 2016 Issue 10

You Be the Coder: Beware Polypectomy and Ablation Limitations

Question: When the surgeon uses a hot snare to ablate a polyp, then during the same session, uses the hot snare to remove a separate polyp, is it correct to code both 45388 and 45385? Alabama Subscriber Answer: Yes, you should be able to report the following two codes together as long as you have documentation that the procedures addressed distinct anatomic sites: 45385 — Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45388 — … with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)...

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