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Edit or missing procedure need ASAP

louise Posted Thu 14th of November, 2019 09:34:03 AM
Rectal polyp incompletly resected billed as 45305 please advise. Path report fragments of tubulovillous adenoma
SuperCoder Answered Fri 15th of November, 2019 02:43:29 AM

Hi Louise,


Provided documentation is not complete. The method and approach used to perform the resection is not mentioned. Was the procedure performed through anal approach or through colonoscopic approach (using colonoscope, sigmoidoscope or proctosigmoidoscope). How was the polyp resected? There are multiple ways of resection like hot biopsy forceps, snare, ablation and other methods.


If no scope was used for resection and approach was anal, you should use CPT code 45171.


For procedure performed through colonoscopy, refer to codes 45384-45385.


For procedures performed through Proctosigmoidoscopy, refer to CPT codes 45308-45309.  


For procedure performed through Sigmoidoscopy, refer to CPT codes 45333.


Hope provided information would be helpful.



louise Posted Mon 18th of November, 2019 14:40:45 PM
External external hemorrhoids. Digital rectal exam revealed a palpable polyp . Anoscopy revealed tattoo area. Rigid proctoscopy was performed, the scar was identified 13cm from anal verge on left side of patient extending anteriorly slightly. There was firm tissue with some erythema. Biopsy forcep was used to perform a rectal polyp biopsy. We were unable to prolapse it down to perform transanal excision.
SuperCoder Answered Tue 19th of November, 2019 03:05:05 AM

Hi Louise,


As per the provided documentation, you should use Use CPT code 45305 for proctoscopy performed with biopsy of tumor. Had the tumor/polyp been completed removed, CPT code 45308 would had been the appropriate code.


Hope, provided information would be helpful.



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