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Tracie Posted Mon 11th of February, 2019 15:33:23 PM
I have a physician who frequently removes colon polyps with cold biopsy forceps, but documents that they are ablated. I am submitting a partial operative report to try to get some clarification on which code should be billed. Thanks for your help. A well lubricated colonoscope was gently inserted per rectum, air was insufflated and scope was advanced up the rectum, navigated throughout the rectosigmoid colon, up the descending colon, across the transverse colon and then dropped down into the cecum. the appendiceal orifice and ileocecal valve were indentified as landmarks. The terminal ileum was briefly intubated and this too appears normal. The scope was then gently withdrawn reexamining the bowel in a 360 degree circumferential fashion. There were no masses, lesions, arterial venous malformation, mucosal inflammation. There was, however, scattered minimal small mouthed open diverticular disease involving all portions of the colon. The scope was withdrawn. Within the sigmoid colon there was a diminutive 5mm semipedunculated polyp. This was affectively ablated with cold forceps technique. Hemostasis was assured. The scope was continuously withdrawn and retroflexed demonstrating the enlarged internal hemorrhoids and several small 1mm flat polyps that are affectively ablated with cold forceps technique. These are ablated and sent to pathology. They are not merely biopsied which would leave portions of the polyp to lead for future neoplasia.
SuperCoder Answered Tue 12th of February, 2019 02:38:41 AM
Hi Tracie nbsp The consensus among most coders is that when the provider uses a technique other than snare or hot biopsy forceps such as cold forceps you should report code Colonoscopy flexible with biopsy single or multiple However a January nbsp CPT nbsp Assistant nbsp article seems to state...

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