Gastroenterology Coding Alert

Question: Our physician excised a 6 mm rectal polyp at the dentate line laterally via electrocautery. The excision had a 2 mm margin. We’ve been unable to find a code that describes a transanal excision of rectal polyp. Which code do you recommend?

New Mexico Subscriber

Answer: You note that the rectal polyp occurred at the dentate line, which is the line between the simple columnar epithelium of the rectum and the stratified epithelium of the anal canal, usually defined as being at the level of the anal valves at the bases of the anal columns. Because of this location, the appropriate code would depend in large part on the approach used.

For example, the most common situation would be during colonoscopy when a snare was used to excise the polyp; this would be covered by 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique), a standard zero-day global service.

If an ablation technique was performed, typically via anoscopy, the code might be 45190 (Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach). This is a 90-day global service usually performed in the OR, with much higher work RVU and includes the anoscopy itself.

If, however, the polyp was located in the perianal skin, and treated by electrodessication, you’d instead report 46910 (Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation). This has a 10-day global service period and includes the anoscopy, and would most commonly be an office procedure.