tci General Surgery Coding Alert - 2006 Issue 9

Reader Questions: Focus Your Colonoscopy Coding on These 2 Words

Question: When performing a colonoscopy, a surgeon finds a miniscule polyp. He applies the tips of the hot biopsy forceps and fulgurates the polyp. No tissue is retrieved for pathology. Is 45383 or 45384 correct?Georgia Subscriber Answer: Because the surgeon ablated, rather than removed, the polyp, you should use 45383. The code's descriptor states, -with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery, or snare technique.- The two operative words are -ablation- and -removal.- The difference between 45383 and 45384 is -ablate- and -remove.- The...

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