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General Surgery Coding Alert

Reader Question:

45380 vs. 45383 Hinges on Documentation

Published on Wed Sep 14, 2011

Question: We have general surgeons at our office who perform many colonoscopies. We're uncertain about the word "ablation," which our medical dictionary defines as "removal of a part, as by incision." Does this mean we can use 45383 for polyp removal by cold biopsy, which would involve sending a specimen to pathology?Michigan SubscriberAnswer: Although you might possibly use 45383 (Colonoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for a polyp removal by cold biopsy, that's probably not the best code choice. Surgeons don't typically send a specimen to pathology following an ablation procedure.The term "ablation" more commonly describes an erosive or corrosive removal, such as laser, cryotherapy, or chemotherapy. If the surgeon describes polyp ablation by any of those methods, 45383 would clearly be the best choice. Better: When the surgeon removes a polyp by [...]
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