Gastroenterology Coding Alert

Question: What code describes this procedure? A single 20 mm pedunculated polyp with no stigmata of recent bleeding was found in the gastric antrum. An endoloop was maneuvered over the polyp stalk and closed at the mucosal attachment prior to removal. Wyoming Subscriber Answer: Your op note does not include the method used to remove the polyp, but it was probably snare technique. Use 43251 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s],polyp[s], or other lesion[s] by snare technique). A gastroenterologist usually applies an endo loop to reduce the chance of bleeding. Control of bleeding is considered included in a polyp removal. The other common methods of polyp removal -- hot forceps or bipolar cautery -- are less likely to cause bleeding. For that you would code 43250 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or [...]