Wiki How do you know when to code 45390 vs 45385, 45381

clarkmegan

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How do you know when to bill 45385, 45381 over 45390? I understand you’re supposed to look for terms such as “flat polyp,” but what if the note doesn’t say that, it just says:

"A single sessile 11 mm polyp was found in the cecum. A piece-meal polypectomy was performed using a hot snare over a saline pillow. The polyp was completely removed.” [/I]

Does a specific location help to determine appropriate CPT code? Ie; are cecal polyps more likely to be flat? Does size of polyp help determine? Looking for some clear cut guidance how to tell from a procedure note when the description is not very specific.
 
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