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General Surgery Coding Alert

Reader Question:
Removal or Ablation Drives Code Choice

Question: As part of a colonoscopy, the surgeon noted internal hemorrhoids, which he ablated using hot biopsy forceps, and a raised sessile diminutive polyp in the sigmoid colon. What procedure code(s) should we use?New York SubscriberAnswer: The answer to your question depends on whether any of the diminutive polyp was removed for pathology analysis, and if so, by what method. If the surgeon used the hot biopsy forceps to ablate the hemorrhoids and take the polyp biopsy, then you should report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). You would also apply this code when the surgeon uses either monopolar hot biopsy forceps or bipolar cautery forceps. However, if the polyp was not amenable to removal, then you should code using 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other [...]


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