Wiki colonoscopy with injection/polypectomy

[anknight77]

Please help with the coding on the following scenario...

In the mid ascending colon there is a polyp. This is a broad based polyp. It is approx. 1 cm in diameter. It has the typical appearance of a tubular adenoma. The polyp was removed in piecemeal fashion. I believe that complete polypectomy is achieved, but that is difficult to ascertain with 100% certainty given the rather flat nature of the polyp and the piecemeal polypectomy. The area was marked with SPOT preparation. Good hemostasis was achieved.

Since the exact same area was tattooed that the polypectomy was done, can I bill for the tattooing?

Thanks in advance for your help!

Amy

 

[coachlang3]

wait, not sure of my answer, let me double check and then repost. But to my gut instinct, yes, you can charge the 45381.

 

[coachlang3]

I didn't know what SPOT prep was and that along with the last sentence (hemostasis was acheived) is what made me do a double look. I thought it was a new way to control bleed, lol.

Yes, you can bill the 45381 and based on what you entered I would also use a 45380 for the piecemeal polyp removal (unless there is different wording in the procedure note).

 

[colorectal surgeon]

Actually, the op note doesn't state how the polypectomy was done. 45380 would be the lesser of the codes. But maybe it was done with a snare and then it would be 45385.