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Gastroenterology Coding Alert

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45385, 45380: Resolve Colon Polyps With 2 Colonoscopy Methods

Published on Tue Mar 08, 2011

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 SubscriberAnswer: Code the procedure using the following: 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for colonoscopy with removal or polyps using snare technique;CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to describe colonoscopy with biopsy;Modifier 59 (Distinct procedural service) attached to 45380 to indicate that it is a different procedure not ordinarily encountered or performed on the same day.Your ICD-9 report should include:V12.72 (Personal history of colonic polyps) to indicate that the patient has a history of colon polyps;211.3 (Benign neoplasm of colon) describes the neoplasm in the patient's colon; and569.89 (Other specified disorders of intestines) [...]
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