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Incisional biopsy of abnormal rectal mucosa

Donna m Posted Mon 23rd of March, 2015 18:51:28 PM

Patient was under anesthesia. Serial dilators were placed into the rectum. Patient had an excision of a recurrent anterior left sided adenoma which was excised & charged as 45171.

I need help with coding this next area - Patient ALSO has an area of abnormal mucosa 2-3 cm in diameter and about 1 cm from proximal to distal. It abutted up againset the anoderm. Dr. was concerned about getting a closure and not positive it represented a sessile ademoa so he did an incisional biopsy and closed it with one suture. Do I charge an unlisted 45999?

SuperCoder Answered Tue 24th of March, 2015 07:30:24 AM

For the next area code 45172 seem to be appropriate as the documentation indicate an area of abnormal mucosa. The Mucosa include epithelium, lamina propria and muscularis mucosa.
Hope that helps

Donna m Posted Tue 24th of March, 2015 11:52:15 AM

This time they only BIOPSIED this, not excised the whole thing. I don't think I can use the 45172 excsion code can I?

The path shows positive margins so now they will need to go back in and remove it all.

SuperCoder Answered Wed 25th of March, 2015 06:25:02 AM

If it was only biopsied then you can use code 45999.

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