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45190 vs 46910 Please advise

louise Posted Wed 24th of June, 2020 18:02:11 PM
Rectal polyp 6 mm polyp at the dentate line laterally on the left that was excised with a few mm margin with electrocautery. Transanal excision of rectal polyp
SuperCoder Answered Thu 25th of June, 2020 06:55:06 AM

Hello Louise,

Hope you’re doing well!


Thank you for your question.


As per the above documentation, since rectal polyp at the dentate line (the line between the simple columnar epithelium of the rectum and the stratified epithelium of the anal canal, usually defined as being at the level of the anal valves at the bases of the anal columns) was excised with electrocautery, the appropriate code would be 45190 (Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach).


Usually, code 46910, is used to report the destruction of lesions on the perianal skin.


Note: Flat or sessile polyps in the distal rectum can spread downwards to the dentate line. These pose several challenges. It can be very difficult to exactly identify the distal edge of these polyps.


Hope that helps!


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