tci General Surgery Coding Alert - 2003 Issue 7

Reader Questions: Multiple Lesions Dont Always Require Multiple Scope Codes

Question: I am new to coding colonoscopies. If the surgeon biopsies multiple polyps in different areas of the colon, should I report 45384 only once?Montana Subscriber  Answer: Yes, for biopsy only during a single colonoscopy, you should report one unit of 45380 (Colonoscopy, flexible, proximal to the splenic flexure; with biopsy, single or multiple), even if the surgeon took several biopsies from different areas. But the technique the surgeon uses does affect coding: If the surgeon used hot biopsy forceps, the appropriate code is 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy...

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