tci General Surgery Coding Alert - 2011 Issue 10

Reader Question: 45380 vs. 45383 Hinges on Documentation

Question: We have general surgeons at our office who perform many colonoscopies. We're uncertain about the word "ablation," which our medical dictionary defines as "removal of a part, as by incision." Does this mean we can use 45383 for polyp removal by cold biopsy, which would involve sending a specimen to pathology?Michigan SubscriberAnswer: Although you might possibly use 45383 (Colonoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for a polyp removal by cold biopsy, that's probably not the best code choice...

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