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General Surgery Coding Alert

Reader Question:

Capture Multiple Scope Procedures

Question: Our surgeon performed a colonoscopy on a patient who had a previous sigmoid colectomy. The surgeon biopsied four polyps, and performed a dilation by balloon due to the anastomosis stricture. Can we code both the biopsy and the balloon dilation? Texas Subscriber Answer: Yes, you can bill for both the balloon dilation and the polyp removal, because the two procedures are medically necessary to address two distinct conditions. Report the following two codes to capture the work your surgeon performed: 45380 -- Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 45386 -- ... with dilation by balloon, 1 or more strictures. You should link the balloon dilation to a stricture diagnosis (e.g., 568.0, Peritoneal adhesions [postoperative], [postinfection]), and the biopsies to a polyp diagnosis (e.g., 211.3, Benign neoplasm of colon). CCI clear: Before reporting codes like this together, you should always check Correct Coding Initiative (CCI) or other [...]