tci General Surgery Coding Alert - 2020 Issue Q1

You Be the Coder: Code to Capture Screening Intent

Question: While performing a screening flexible sigmoidoscopy, the surgeon detected and removed a distal-colon polyp by snare technique. How should I code this case? Louisiana Subscriber Answer: The answer depends partly on the payer. For Medicare, the correct code for a screening colonoscopy is G0104 (Colorectal cancer screening; flexible sigmoidoscopy), but most non-Medicare payers accept the CPT® code 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). Once the surgeon removes a polyp, the situation changes to a diagnostic procedure, which in this case, codes to 45338 (…with removal of tumor[s]...

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