# Colonoscopies several techniques



## ATMOCH88 (Mar 6, 2013)

Pre-op Diagnosis: anorectal bleeding

Post-op Diagnosis: polyps

Procedure: colonoscopy with polyp ablation, snare polypectomy, polyp biopsy  

Specimen:  

1. Descending colon polyps x3, ~4mm each, removed with cold biopsy forceps.

2. Sigmoid polyp x4, ~5mm each, removed with hot snare and retrieved.

3. Rectal polyps x3, ~5mm each, removed with hot snare and retrieved.


Findings: 
1. Descending colon polyps x3, ~4mm each, removed with cold biopsy forceps.

2. Sigmoid polyp x4, ~5mm each, removed with hot snare and retrieved.

3. Sigmoid polyp, <3mm, ablated with cautery using tip of snare.

4. Rectal polyps x3, ~5mm each, removed with hot snare and retrieved.

5. Rectal polyps x3, <3mm, ablated with cautery using tip of snare.



Indication:  

Patient is undergoing a colonoscopy for a history of anorectal bleeding.  

Description of Procedure:  

Once the patient was adequately sedated, DRE was performed that revealed normal sphincter tone and no gross blood or palpable masses.

The colonoscope was then inserted at the anus and insufflation was performed. The colonoscope was advanced the full length of the colon to the cecum under direct visualization. Location of the cecum was confirmed by visualization of the appendiceal orifice, I.C. Valve, coalescence of the teniae, and with direct palpation of the RLQ of the abdomen. The colonoscope was slowly withdrawn under direct visualization as the colon was serially desufflated. The ascending, transverse, descending, sigmoid colon and rectum had normal appearing mucosa without polyps except as noted and dealt with in the findings.  Final desufflation was performed and the colonoscope was withdrawn completely from the patient.  



The surgeon billed out 

45383
45385.51
45380.51


Can the ablation code 45383 be used in this senerio.  I have been advised that you may not use 45383 if hot biopsy forceps, bipolar cauterization, or snare techique are used for the ablation.  In the operative report it states that they used the tip of the snare for the ablation.


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## dingersol (Mar 6, 2013)

Let's start by looking at some information that's contained in the following op note;

In the right colon, two 6 to 7mm polyps were noted. Using snare polypectomy technique with cautery both of these polyps were removed. The colonoscope was then withdrawn into the rectum where a small, flat 1 or 2mm polyp was found and this time the polyp was ablated using cautery from the tip of the polypectomy snare. 

The question is, should a coder report 45383 (ablation) in addition to 45385 (snare) for the rectal polyp that was ablated?

No, not according to the AMA which refers to information from the American Society for Gastrointestinal Endoscopy (ASGE). Ablation of small polyp(s) is not often performed as a stand-alone procedure, but commonly will occur when using a snare to remove much larger polyps. When it's not necessary to submit a tissue specimen and the same tool is used to expedite removal the physician work involved does not warrant reporting an additional CPT code. There is also the argument that this type of polyp would be amenable to removal by other techniques (biopsy forceps, hot biopsy, or bipolar cautery) so for the example listed above the only service that should be reported is 45385 – Colonoscopy with removal of tumor(s), polyps(s), or other lesion(s) by snare technique.

http://www.mdstrategies.com/nl_09_10.html

Based on the documentation I think the op report reflects small lesions similar to those in this article?  
I think they should use the hot snare and cold forceps - those are the only methods he stated were used.  I don't think something consequently found that was less than 3mm that was touched with the tip of the hot snare meets the criteria the AMA set out for the ablation code - just my opinion based on the documentation and coding guidelines. 
Hope that reference helps you find supportive guidelines I could not locate a CPT Asst for you.

Debbie


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## JDV7980 (Mar 14, 2013)

Hi there.. No, I would not use the ablation code 45383.  You are correct!

I would code it as...

45385       -211.3, 211.4     -sigmoid/rectum
45380, 59 -211.3               -descending colon

You can even document on the claim form (box 19) the area the polyp was removed from (as I did above).  The ICD-9 codes tell the story in this case, but if it was just the 211.3 the insurance may want to know why you are requesting both codes for the same thing (thus delaying payment) so it's just nice to let them know up front what part of the anatomy the polyps were removed from instead of going back and forth  Hope this helps!


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