Wiki Please help with this case study....

[lidad99]

Patient comes in for colonoscopy for diarrhea and right lower quadrant abdominal pain. The transverse colon showed aphthous ulcerations. Multiples biopsies were taken of the ulcerated area to rule out Crohn's disease. A 2 cm sessile polyp was removed from the descending colon via snare technique. The sigmoid colon revealed minimal scattered diverticulosis. Path report revealed a benign villoglandular polyp and active chronic colitis of the transverse colon, Crohn's disease ruled out.


I would really appreciate some assistance on this....

 

[Torilinne]

Help with Case Study

I'd code a 45385 for the snare polyp removal, using 211.3 as the diagnosis. Your second CPT would be 45380 with modifier 59 for the multiple biopsies taken of the transverse colon with diagnosis 556.0 first and 562.10 as a second diagnosis. Hope this helps!