Wiki polyps removal

[elenax]

I see two techniques used on this report: 45385 + 45380...do you collegues agree


PROCEDURE: Pancolonoscopy with multiple polypectomies.


An Olympus CF-140L video colonoscope was passed per anus and advanced without much difficulty, all the way to the apex of the cecum. The appendiceal orifice and ileocecal valve were distinctly identified. Upon withdrawing the scope, the entire colon was examined very well. At the ascending colon, there were three flat, sessile 3-5 mm polyps. All of these were removed completely by electrocautery forceps. At the transverse colon there were four, flat, sessile 3-4 mm polyps. These were likewise removed. At the proximal sigmoid colon, there were two flat, sessile, 3-4 mm polyps, which were again removed by electrocautery forceps. There were a few diverticula noted at the sigmoid colon. At the 20 cm sigmoid colon, there was a 6-7 mm sessile polyp. This was removed completely by snare cautery and retrieved. The rectum was examined well on both and J-maneuver, and appeared normal. Flat, internal hemorrhoids were seen.

The patient tolerated the procedure very well.

PREOPERATIVE DIAGNOSIS:
1. Status post removal of multiple adenomatous colon polyps.
2. Family history of colon cancer.

POSTOPERATIVE DIAGNOSIS:
1. Multiple benign appearing sessile polyps. All were removed as described above.
2. Mild diverticulosis of the sigmoid colon.

 

[Anna Weaver]

polyp removal

I see two techniques used on this report: 45385 + 45380...do you collegues agree


PROCEDURE: Pancolonoscopy with multiple polypectomies.


An Olympus CF-140L video colonoscope was passed per anus and advanced without much difficulty, all the way to the apex of the cecum. The appendiceal orifice and ileocecal valve were distinctly identified. Upon withdrawing the scope, the entire colon was examined very well. At the ascending colon, there were three flat, sessile 3-5 mm polyps. All of these were removed completely by electrocautery forceps. At the transverse colon there were four, flat, sessile 3-4 mm polyps. These were likewise removed. At the proximal sigmoid colon, there were two flat, sessile, 3-4 mm polyps, which were again removed by electrocautery forceps. There were a few diverticula noted at the sigmoid colon. At the 20 cm sigmoid colon, there was a 6-7 mm sessile polyp. This was removed completely by snare cautery and retrieved. The rectum was examined well on both and J-maneuver, and appeared normal. Flat, internal hemorrhoids were seen.

The patient tolerated the procedure very well.

PREOPERATIVE DIAGNOSIS:
1. Status post removal of multiple adenomatous colon polyps.
2. Family history of colon cancer.

POSTOPERATIVE DIAGNOSIS:
1. Multiple benign appearing sessile polyps. All were removed as described above.
2. Mild diverticulosis of the sigmoid colon.

I think I would go with 45384 and 45385. I found several articles that indicate bipolar and electrocautery forceps are the same thing (Google electrocautery forceps), so I would use the 45384 instead of the 45380.
any other opinions?

Anna

 

[lring]

polyp removal

I would use codes 45385 and 45384-51

because all polyps were removed or cauterized - I would not use the 45380 for biopsy

(listed in this order with the -51 on the 45384 based on RVU table from Mcare)

 

[LTibbetts]

I disagree on the -51 modifier. I always use the -59 modifier for colonoscopies.

CPT Assistant, January 2004

"If different techniques are used on separate sites then the code with the highest value should be listed should be listed first on the claim. Other codes should be listed in descending order of value with the modifier -59 to identify that the service was performed at a separate site."

which in your op note, the polyps were in different locations. Also, the OPPS audit should catch that and make sure that you know that a modifier -51 isn't an appropriate modifier for those procedures and to use the -59.

 

[mbort]

Leslie is absolutely correct, this is an ASC as well, therefore the 51 is not even a valid modifier. 59 Modifier is the appropriate modifier.