Coding colonoscopies may be difficult due to variable physician documentation.
For example, when referring to a polyp, a physician may document that he or she "removed in its entirety" or removed it "piece-meal."
Fortunately, these terms are not relevant to selecting the correct CPT code. Instead, coders should base code selection on the technique used to resect the tissue.
However, when a physician uses multiple techniques, only report one CPT code, regardless of whether the physician used the technique to resect single or multiple polyps, or whether he or she used the technique multiple times on a single polyp.
Whether the verbiage in the operative report simply states that the physician removed the polyp by snare polypectomy or that he or she removed it "piece-meal" with a snare, report both procedures using CPT code 45385.
This tip is brought to you by Ellis Medical Consulting, Inc.
