Endoscopic mucosal resection (EMR)

During a colonoscopy, a 1 cm sessile polyp was identified in the cecum. The polyp was removed by endoscopic mucosal resection (EMR) using the underwater EMR technique. Water was pumped into the cecum completely submerging the polyp underwater isolating it from the underlying mucosa. The polyp was then removed via hot snare polypectomy. What is the correct code for this procedure? Is a code assigned for an EMR if the polyp was lifted via water rather than a submucosal injection or is this reported as a colonoscopy with snare removal? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium coding article focuses on a colonoscopy case involving endoscopic mucosal resection techniques and how documentation details influence procedure reporting. It is aimed at coding professionals, auditors, and clinicians who document or review endoscopic gastrointestinal procedures. The article addresses the general documentation elements relevant to EMR reporting and the distinction between EMR and snare-based colonoscopy reporting.

Why This Topic Matters

Correctly identifying whether the documentation supports EMR reporting affects code selection and compliant procedure abstraction for gastrointestinal endoscopy services. The article is relevant when technique details and documentation completeness determine how a colonoscopy encounter should be coded.

What You Will Learn

  • How an EMR colonoscopy scenario is evaluated from a coding documentation perspective.
  • What types of documentation details may need clarification before reporting an EMR procedure.
  • How endoscopic technique documentation can affect gastrointestinal procedure coding.
  • How coding review may distinguish EMR-related reporting from standard snare removal reporting.

Who Should Read This

  • Medical coders
  • Coding auditors
  • Compliance staff
  • Gastroenterology practices
  • Clinical documentation specialists

Codes Discussed

  • CPT: 45390

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