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Question: I have the following documentation in an operative note:

A single sessile 5 mm polyp of benign appearance was found in the rectum. A piece-meal polypectomy was performed using cold forceps. The polyp was completely removed.

A single semi-pedunculated 10 mm polyp of benign appearance was found. Also used hot forceps sparingly... A single-piece polypectomy was performed using a hot snare. The polyp was completely removed.

A single sessile 5 mm polyp of benign appearance was found in the rectum. A piece-meal polypectomy was performed using cold forceps. The polyp was completely removed.

Can you explain which CPT^庐 codes I need to report the procedure?

Georgia Subscriber

Answer: You鈥檒l assign two CPT^庐 codes and append a modifier to one of the codes. Assign 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) to report the semi-pedunculated 10 mm polyp that the physician removed with a hot snare. Next, you鈥檒l assign 45380 (Colonoscopy, flexible; with biopsy, single or multiple) to report the multiple sessile 5 mm polyps removed via cold forceps.

Then, you鈥檒l append modifier 59 (Distinct procedural service) to 45380 to show the 5 mm polypectomies were a separate and distinct procedure during the same session. This is because the physician removed the polyps using different techniques (cold forceps versus hot snare) and the polyps were likely in separate locations.

Important: Make sure the documentation includes the sites and techniques used for each polyp removal.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC