Question

Preoperative Diagnosis: Guiac positive stools

Postoperative diagnosis: Multiple colon polyps, diverticulosis

Procedure: Total colonoscopy with biopsy and polypectomy

Description: This is a 65 year old male who was found to have guiac positive stools on a routine exam.

The patient was brought to the endoscopy suite and placed in a left lateral decubitus position. 50 mg of Demorol and 2 mg Versed were administered. Digital rectal examination was done, which was normal. Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen. It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine. The scope then was advanced through rest of the transverse colon to ascending colon and cecum. Terminal ileum was briefly reviewed, appeared normal and so did cecum. Ascending colon was unremarkable. At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine. In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy. Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy. Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy. The rest of the splenic flexure and descending colon were unremarkable. Diverticulosis was again seen with almost constant spasm despite of glucagon. The endoscope was withdrawn.

PLAN: Await biopsy report. Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.

CPT code(s) with description:

Answer 1

CPT Code(s): 45385, 45384-59

Description:

According to the CPT coding guidelines, polypectomy should be coded based on the different techniques used and not on number of polyps. In this case, the transverse colon three of the sessile polyps were removed by the use of colonoscopy in the transverse colon, proximal to hepatic flexure, and near splenic flexure by snare technique. so it is coded as 45385. Additional polyp is removed by a hot biopsy technique. So it coded as 45384. Modifier -59 is used for biopsy, multiple removals of polyps and for distinct procedures.