tci Outpatient Facility Coding Alert - 2015 Issue 1

You Be the Coder: Coding for Colon Polyps Resolved With Colonoscopy Methods

Question: How should I report the procedure based on this physician’s notes: “Patient with history of colon polyps; Ileocecal valve was prominent and somewhat displaced and was biopsied extensively. Sessile polyps removed by snare from transverse and descending colon” Michigan Subscriber Answer: Code the procedure using the following procedure codes: 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for colonoscopy with removal or polyps using snare technique; 45380 (Colonoscopy, flexible; with biopsy, single or multiple) to describe colonoscopy with biopsy; Modifier 59 (Distinct procedural service) or one of the new X{EPSU}...

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