The scenario involves a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric polyp. The physician documents the procedure and the finding of a 1.5 cm sessile polyp in the gastric antrum, which was successfully removed via hot snare polypectomy. The pathology report confirms the polyp is a hyperplastic polyp with no evidence of dysplasia or malignancy. To correctly code this encounter for Certified Gastroenterology Coder (CGIC) University standards, we need to identify the appropriate CPT codes for the procedure and any related diagnostic services. The primary procedure is the EGD with biopsy and removal of a gastric polyp. CPT code 43239 (Esophagogastroduodenoscopy, flexible, with biopsy, single or multiple specimens, or submucosal injection) covers the EGD with biopsy. However, when a polyp is removed during an EGD, a more specific code is often applicable. CPT code 43274 (Esophagogastroduodenoscopy, flexible, with removal of foreign body, endoscopic stent, or prosthesis; or endoscopic polypectomy/mucosal resection) accurately reflects the polypectomy. Since the polyp was removed, this code is more appropriate than a simple biopsy code. The size of the polyp (1.5 cm) and the method of removal (hot snare polypectomy) are important documentation details that support the use of this code. The pathology report confirming a hyperplastic polyp without dysplasia is crucial for diagnostic coding (ICD-10-CM), but the CPT code focuses on the service performed. No additional diagnostic imaging or separate therapeutic interventions were performed that would warrant other CPT codes. Therefore, the most accurate CPT code for the physician’s service is 43274.

The scenario involves a patient undergoing a diagnostic colonoscopy with polyp removal and a subsequent biopsy of a suspicious lesion in the sigmoid colon. The physician documents the complete colonoscopy, the removal of a 1.5 cm sessile polyp in the transverse colon via snare polypectomy, and a separate biopsy of a 0.8 cm ulcerated lesion in the sigmoid colon. For the colonoscopy with polypectomy, the primary procedure code is for a colonoscopy with removal of a lesion. The size of the polyp (1.5 cm) and the method of removal (snare) are critical for accurate coding. The appropriate CPT code for a colonoscopy with snare polypectomy of a lesion greater than or equal to 0.5 cm is 45385. For the biopsy of the sigmoid lesion, the physician performed a separate diagnostic procedure on a different lesion. The CPT code for a colonoscopy with biopsy of a lesion is 45380. Since these are distinct procedures performed on separate lesions during the same encounter, both codes are generally reportable. However, the National Correct Coding Initiative (NCCI) edits must be considered. In this case, a colonoscopy with biopsy (45380) is a component of a colonoscopy with snare polypectomy (45385). Therefore, when both are performed, the more comprehensive procedure code is reported, and the less comprehensive one is typically bundled. The NCCI edits would likely bundle the biopsy code into the polypectomy code when performed on separate lesions during the same encounter, as the base colonoscopy is the same. However, the question specifies *separate* lesions. When distinct lesions are addressed, and one is a polypectomy and the other a biopsy, the correct coding practice often involves reporting both if they are distinct and separately identifiable. The correct approach is to report the more complex procedure, which is the snare polypectomy, and the biopsy of a separate lesion. The NCCI edits for colonoscopy procedures often bundle biopsies into polypectomies when performed on the *same* lesion, but not necessarily when performed on *distinct* lesions. In this specific scenario, the documentation clearly indicates two separate lesions, one removed by polypectomy and another biopsied. Therefore, the most accurate coding would involve reporting the snare polypectomy and the biopsy. The CPT code for a colonoscopy with snare polypectomy of a lesion greater than or equal to 0.5 cm is 45385. The CPT code for a colonoscopy with biopsy of a lesion is 45380. When both are performed on separate lesions, the primary procedure is the more extensive one, and the secondary procedure is also reported with appropriate modifiers if necessary, or if NCCI allows. However, given the common bundling rules for colonoscopies where multiple biopsies or a biopsy and polypectomy on the *same* lesion are performed, the question tests the understanding of distinct lesion coding. The correct coding is to report the snare polypectomy and the biopsy of the separate lesion. The CPT code for colonoscopy with snare polypectomy of a lesion >= 0.5 cm is 45385. The CPT code for colonoscopy with biopsy of a lesion is 45380. When both are performed on separate, distinct lesions, both can be reported, with the more extensive procedure being the primary. The question tests the understanding of distinct lesion coding in the context of NCCI edits. The correct approach is to report the snare polypectomy and the biopsy of the separate lesion. The CPT code for colonoscopy with snare polypectomy of a lesion >= 0.5 cm is 45385. The CPT code for colonoscopy with biopsy of a lesion is 45380. When both are performed on separate, distinct lesions, both can be reported, with the more extensive procedure being the primary. The correct coding is to report both procedures as they were performed on separate lesions. The CPT code for colonoscopy with snare polypectomy of a lesion >= 0.5 cm is 45385. The CPT code for colonoscopy with biopsy of a lesion is 45380. Therefore, the correct coding is 45385 and 45380. The correct answer is 45385 and 45380.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, non-bleeding polyp. The physician also performs a biopsy of a separate, distinct area of abnormal mucosa in the sigmoid colon. For accurate coding at Certified Gastroenterology Coder (CGIC) University, understanding the nuances of CPT coding for these distinct procedures is paramount. The colonoscopy itself is reported with CPT code 45378 (Colonoscopy, flexible, sigmoidoscopy, and/or proctosigmoidoscopy; diagnostic, with or without collection of specimen(s), but without removal of foreign body or polyp). The removal of the polyp, when performed during the diagnostic colonoscopy, is typically included in the primary diagnostic code unless it meets specific criteria for separate reporting (e.g., extensive snare removal of a large, sessile polyp requiring significant additional time and effort, which is not indicated here). However, the biopsy of a separate site is a distinct procedural service. CPT code 45380 (Colonoscopy, flexible, sigmoidoscopy, and/or proctosigmoidoscopy; with biopsy, single or multiple specimens) accurately reflects this additional service. When multiple distinct procedures are performed during the same session, modifiers are crucial for proper reimbursement and to indicate the nature of the services. In this case, the biopsy is considered a secondary procedure to the diagnostic colonoscopy. Therefore, the appropriate modifier to append to the biopsy code (45380) is the 59 modifier (Distinct Procedural Service), indicating that the biopsy was a separate, distinct procedure from the diagnostic colonoscopy and polyp removal. The diagnostic colonoscopy (45378) would be reported without a modifier, as it is the primary service. The correct coding combination is 45378 and 45380-59.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician’s documentation clearly indicates the reason for the colonoscopy (screening for colorectal cancer due to family history) and the identification and biopsy of a polypoid lesion. The biopsy report confirms the presence of adenocarcinoma. To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, one must consider the primary reason for the encounter and any procedures performed. The initial encounter is for screening due to a family history of colorectal cancer. However, during the screening, a lesion is found and biopsied, and subsequently diagnosed as malignant. This changes the coding focus from a screening encounter to a diagnostic and therapeutic one. The ICD-10-CM code for screening colonoscopy due to family history is Z13.79 (Encounter for screening for other specified congenital malformations). However, once a lesion is identified and biopsied, and a malignancy is diagnosed, the screening code is no longer appropriate as the primary diagnosis. The correct ICD-10-CM code for the diagnosed condition, adenocarcinoma of the sigmoid colon, is C18.7 (Malignant neoplasm of sigmoid colon). For the CPT coding, a colonoscopy with biopsy of a polypoid lesion is reported. The base colonoscopy code is 45385 (Colonoscopy with biopsy, single or multiple). Since the biopsy was performed, this code accurately reflects the procedure. If multiple biopsies were taken from different sites, or if other procedures like polypectomy were performed, additional codes might be applicable, but based on the provided information, 45385 is the primary procedural code. The question asks for the most appropriate coding combination reflecting the diagnostic outcome and the procedure performed. Therefore, the combination of the malignant neoplasm code and the colonoscopy with biopsy code is the correct approach. The explanation focuses on the transition from screening to diagnostic coding upon the identification and biopsy of a lesion that is subsequently confirmed as malignant, aligning with the principles of accurate medical record abstraction and coding for clinical and reimbursement purposes at CGIC University.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, sessile polyp in the sigmoid colon. The physician also performs a biopsy of a separate, non-polypoid lesion in the transverse colon. For the colonoscopy itself, the primary CPT code is 45378 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without examination of the ileum, with or without specimen collection(s), with or without removal of foreign body). When a polyp is removed during a colonoscopy, an additional CPT code is appended to indicate this service. The appropriate code for the removal of a single polyp is 45385 (Colonoscopy, flexible, sigmoidoscopy, flexible; with removal of tumor(s), 1 or more; using hot biopsy forceps or electrothermal biopsy). The biopsy of the separate lesion in the transverse colon requires its own CPT code. The correct code for a biopsy taken during a colonoscopy is 45380 (Colonoscopy, flexible, sigmoidoscopy, flexible; with biopsy, single or multiple). Therefore, the correct coding combination involves reporting the base colonoscopy, the polyp removal, and the separate biopsy. The rationale for this coding is to accurately reflect the distinct procedures performed during the single endoscopic session, ensuring appropriate reimbursement and adherence to coding guidelines for multiple distinct services. The use of modifier -59 (Distinct Procedural Service) is not necessary here because the biopsy and polyp removal are distinct services that are separately reportable with their own CPT codes when performed during the same colonoscopy. The question tests the understanding of coding for multiple procedures performed during a single endoscopic encounter, specifically differentiating between polyp removal and biopsy, and the correct application of CPT codes without unnecessary modifiers.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion. The physician performs the colonoscopy and identifies a polypoid lesion in the sigmoid colon, from which a tissue sample is obtained for histopathological examination. The documentation indicates the lesion was visualized and a biopsy was performed. For accurate coding, we need to identify the appropriate Current Procedural Terminology (CPT) codes. The primary procedure is the colonoscopy. According to CPT guidelines, a diagnostic colonoscopy is reported with code 45378. Since a biopsy was performed during the colonoscopy, an additional code is required to represent this service. The CPT code for a biopsy of the colon, performed during a colonoscopy, is 45380. When multiple procedures are performed during the same operative session, modifiers may be necessary. However, in this specific instance, CPT guidelines for colonoscopies and biopsies indicate that the biopsy code (45380) is often considered an integral part of the diagnostic colonoscopy when performed on the same lesion. Therefore, reporting both 45378 and 45380 without a modifier would typically be incorrect as per NCCI edits, which bundle the biopsy into the diagnostic colonoscopy. The correct approach is to report the more comprehensive procedure that includes the biopsy. In this case, the biopsy is performed on a lesion identified during the diagnostic colonoscopy. CPT code 45380 specifically describes “Colonoscopy with biopsy, single or multiple specimens.” This code encompasses both the visualization and the tissue sampling. Therefore, 45380 is the most appropriate code to report as it includes the biopsy. If the physician had performed a separate diagnostic colonoscopy *and then* a therapeutic intervention on a *different* lesion, or if the biopsy was performed on a separate, distinct lesion not directly related to the primary diagnostic finding, then reporting both might be considered with appropriate modifiers. However, based on the description of a biopsy of a suspicious lesion identified during the diagnostic colonoscopy, 45380 is the correct single code.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion. The physician documents the procedure as a complete colonoscopy (CPT code 45378) and the removal of a polyp via snare (CPT code 45385). Additionally, a biopsy of a separate, distinct lesion in the sigmoid colon was performed using forceps. The key to accurate coding lies in understanding the nuances of reporting multiple procedures on the same anatomical structure during a single encounter, particularly when distinct lesions are addressed. For the colonoscopy itself, the base code for a diagnostic colonoscopy is 45378. The removal of a polyp via snare is a distinct therapeutic service performed during the colonoscopy, and is reported with 45385. When multiple distinct lesions are addressed during a colonoscopy, and one is removed and another is biopsied, the correct coding requires reporting the most extensive procedure performed on each distinct lesion. In this case, the polyp removal (45385) is more extensive than the snare biopsy (45384). The biopsy of the separate sigmoid lesion using forceps is reported with CPT code 45384. When multiple endoscopic procedures are performed on the same day, and one is more extensive than the others, the primary procedure is reported with its full RVUs, and subsequent less extensive procedures on different sites or lesions may be subject to modifier -59 (Distinct Procedural Service) or the newer -X{S,U,P,K} modifiers if applicable and appropriate to indicate they are distinct from the primary service. However, the National Correct Coding Initiative (NCCI) edits often bundle certain endoscopic procedures. In this specific scenario, the NCCI edits typically bundle diagnostic colonoscopy (45378) into therapeutic colonoscopies like polyp removal (45385) and snare biopsies (45384). Therefore, 45378 would not be separately reported. The polyp removal (45385) is the most extensive procedure performed on one lesion. The biopsy of the separate sigmoid lesion (45384) is a distinct procedure on a different lesion. NCCI guidance for colonoscopies generally allows reporting of separate therapeutic or diagnostic procedures on distinct lesions. The correct approach is to report the most extensive procedure for each distinct lesion. Therefore, 45385 for the polyp removal and 45384 for the sigmoid biopsy are reported. Since 45385 is more extensive than 45384, it is typically reported first, and 45384 would be reported with modifier -59 to indicate it is a distinct procedural service from the polyp removal. The calculation is as follows: CPT code for polyp removal via snare: 45385 CPT code for biopsy of a separate lesion via forceps: 45384 Modifier for distinct procedural service: -59 Final coding: 45385, 45384-59. This approach aligns with the principle of reporting all services rendered, ensuring that the complexity and distinct nature of each intervention are accurately captured for reimbursement and quality reporting purposes, which is a core tenet of Certified Gastroenterology Coder (CGIC) University’s curriculum emphasizing precise documentation and coding. Understanding the bundling edits and the appropriate use of modifiers like -59 is crucial for maintaining compliance and accurately reflecting the physician’s work, a skill honed through rigorous training at CGIC University.

The scenario describes a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a suspicious lesion in the gastric antrum. The physician also performs a separate diagnostic upper endoscopy of the esophagus and duodenum without additional interventions in these areas. The key to accurate coding lies in identifying the primary procedure and any separately reportable diagnostic services. The EGD with biopsy of the gastric antrum is the most comprehensive and invasive procedure performed. According to CPT guidelines, when multiple diagnostic or therapeutic services are performed during a single endoscopic session, the most extensive procedure is typically reported. In this case, the EGD with biopsy is the primary service. The diagnostic upper endoscopy of the esophagus and duodenum, while technically a separate examination of distinct anatomical segments, is inherently included within the scope of a complete EGD that visualizes these areas. Reporting a separate diagnostic EGD for the esophagus and duodenum would constitute unbundling, as these components are integral to the overall EGD. Therefore, the correct coding approach is to report the EGD with biopsy of the gastric antrum using the appropriate CPT code. The explanation for this choice is that the diagnostic components of the esophagus and duodenum are subsumed within the more comprehensive EGD procedure that includes the antral biopsy. The intent of the question is to assess the understanding of bundled services and the principle of reporting the highest level of service performed.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, sessile polyp in the sigmoid colon. The physician also performs a separate, diagnostic biopsy of a suspicious lesion in the ascending colon. For the colonoscopy itself, the primary CPT code is 45378 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without sigmoidoscopy, with or without colonoscopy, with or without examination of the ileum, with or without biopsy, with or without removal of artifact, with or without insertion of indwelling tube or catheter). However, since a polyp was removed, an add-on code is required. The appropriate add-on code for polyp removal during a colonoscopy is 45385 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without sigmoidoscopy, with or without colonoscopy, with or without examination of the ileum, with or without biopsy, with or without removal of artifact, with or without insertion of indwelling tube or catheter; with endoscopic mucosal resection). The biopsy of the ascending colon lesion is a separate procedure and requires its own CPT code. The correct code for a diagnostic biopsy during a colonoscopy is 45380 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without sigmoidoscopy, with or without colonoscopy, with or without examination of the ileum, with or without biopsy, with or without removal of artifact, with or without insertion of indwelling tube or catheter; with biopsy, single or multiple). When multiple procedures are performed during the same operative session, and one is not integral to the other, the primary procedure is coded with the full RVU, and subsequent procedures are coded with a reduced RVU, often indicated by a modifier. In this case, the polyp removal (45385) is considered the primary procedure, and the biopsy (45380) is a secondary procedure. Therefore, the correct coding would involve reporting both 45385 and 45380. The National Correct Coding Initiative (NCCI) edits would typically bundle a biopsy into a polypectomy if performed on the same polyp, but here they are distinct findings and interventions. The question asks for the most appropriate coding combination for the described services. The combination of 45378 and 45385 is incorrect because 45378 is the base code for colonoscopy and 45385 is an add-on code that already includes the base colonoscopy service. The combination of 45380 and 45385 accurately reflects both the polypectomy and the separate biopsy. The combination of 45378 and 45380 is incorrect because it fails to account for the polyp removal. The combination of 45380 and 45378 is incorrect for similar reasons as the first incorrect option, as 45378 is superseded by the more specific codes for interventions. The correct approach is to report the most comprehensive code for the primary intervention (polypectomy) and the appropriate code for the secondary intervention (biopsy), ensuring that no procedure is double-billed or inaccurately represented.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion. The physician documents the procedure, including the visualization of the lesion, the decision to biopsy, and the removal of tissue for pathological examination. For accurate coding, the primary procedure is the colonoscopy itself. The biopsy is an integral part of the diagnostic workup of a lesion identified during the colonoscopy. According to standard coding guidelines for gastroenterology, when a diagnostic colonoscopy is performed and a lesion is identified and biopsied, the biopsy is typically not reported separately with a modifier if it’s considered part of the same encounter and diagnostic intent. The focus is on the diagnostic colonoscopy, which includes the examination and any necessary tissue sampling for diagnosis. Therefore, the appropriate coding would reflect the diagnostic colonoscopy. The complexity arises in understanding when a biopsy is considered a distinct, separately billable service versus an integral component of a diagnostic procedure. In this case, the biopsy serves the diagnostic purpose of the colonoscopy, making it an inherent part of the overall diagnostic encounter. The question tests the understanding of bundling principles and the specific application within gastrointestinal endoscopy coding, particularly concerning biopsies of identified lesions during a diagnostic examination. The correct approach is to identify the primary diagnostic procedure and recognize that the biopsy, in this context, is bundled.

The scenario describes a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric polyp. The physician documents the procedure, including the identification and removal of a 1.5 cm sessile polyp in the gastric antrum, which is then sent for histopathological examination. The question asks for the most appropriate CPT code for this encounter, considering the specific services provided. The core procedure is an EGD, which falls under the category of diagnostic endoscopy of the upper gastrointestinal tract. The base code for an EGD is typically found in the 43235-43259 range. Since a biopsy was performed, the code must reflect this additional service. The physician performed a biopsy of a gastric polyp. The CPT manual provides specific codes for endoscopic procedures with biopsy. For an EGD with biopsy of the stomach, the appropriate code is 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, submucosal injection(s), or placement of internal device(s) (not including removal of foreign body or polyp)). The size of the polyp (1.5 cm) and its location (gastric antrum) are important clinical details but do not alter the selection of the base biopsy code for an EGD. The removal of a polyp would typically be coded separately if it were a polypectomy, but the documentation specifies a biopsy. Therefore, the most accurate coding reflects the EGD with biopsy.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, non-pedunculated polyp. The physician also performs a biopsy of a separate, abnormal-appearing area of the sigmoid colon that was not removed. For the colonoscopy itself, the base code for a diagnostic colonoscopy is 45378. The removal of a single, non-pedunculated polyp is reported with add-on code 45385. The biopsy of the separate abnormal area is reported with add-on code 45380. Therefore, the correct coding combination is 45378, 45385, and 45380. This combination accurately reflects the diagnostic procedure, the therapeutic removal of a lesion, and the diagnostic sampling of another distinct area, all within the same encounter. Understanding the nuances of add-on codes and their specific indications for different types of polyp removal or tissue sampling is crucial for accurate reimbursement and reflects the detailed procedural knowledge expected of a Certified Gastroenterology Coder at Certified Gastroenterology Coder (CGIC) University. The correct approach involves identifying each distinct service performed during the endoscopic session and applying the appropriate CPT code, ensuring that all services are captured without unbundling or overcoding.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician also performs a separate, unrelated polypectomy of a small adenomatous polyp in the transverse colon during the same encounter. The key to accurate coding lies in understanding the National Correct Coding Initiative (NCCI) edits and the principles of coding for multiple procedures performed during a single session. A colonoscopy (CPT code 45378) is the primary diagnostic procedure. The biopsy of the sigmoid colon lesion is separately reportable as it is a distinct diagnostic action performed on a specific site. The appropriate CPT code for a biopsy of the colon is 45380. The polypectomy of the adenomatous polyp in the transverse colon is also a distinct therapeutic procedure. The appropriate CPT code for a colonoscopic polypectomy is 45385. When multiple procedures are performed during the same endoscopic session, NCCI edits often bundle less extensive procedures into more comprehensive ones. However, a diagnostic colonoscopy (45378) is typically the base code. A biopsy (45380) is considered a more extensive diagnostic procedure than a simple visual examination. A polypectomy (45385) is a therapeutic procedure. According to NCCI guidelines, when a biopsy and a polypectomy are performed during the same colonoscopy, the polypectomy code (45385) generally takes precedence over the biopsy code (45380) if the biopsy is performed on the same lesion that is removed. However, in this case, the biopsy is from a *suspicious lesion* in the sigmoid colon, and the polypectomy is from a *separate adenomatous polyp* in the transverse colon. These are distinct lesions in different anatomical locations. Therefore, the correct coding approach is to report the colonoscopy with the biopsy and the separate polypectomy. The colonoscopy itself is the base. The biopsy of the sigmoid lesion is coded as 45380. The polypectomy of the transverse colon polyp is coded as 45385. When reporting multiple procedures from the same family of codes, a modifier is often required to indicate that distinct services were performed. Modifier 59 (Distinct Procedural Service) or its newer alternatives like modifier 51 (Multiple Procedures) or modifier 22 (Increased Procedural Services) might be considered depending on payer policies and the specific circumstances. However, the question asks for the *most appropriate coding approach* for the procedures themselves, assuming proper documentation supports distinct services. The most accurate coding reflects the distinct services performed: the colonoscopy, the biopsy of the sigmoid lesion, and the polypectomy of the transverse colon polyp. The colonoscopy (45378) serves as the base for the diagnostic and therapeutic interventions. The biopsy (45380) is for the sigmoid lesion. The polypectomy (45385) is for the transverse colon polyp. The principle of reporting distinct procedures applies here. The colonoscopy is the overarching examination. The biopsy is a separate diagnostic action on one lesion. The polypectomy is a separate therapeutic action on another lesion. Therefore, the combination of the colonoscopy, the biopsy code, and the polypectomy code, with appropriate modifiers if required by payers, represents the correct coding. The question focuses on the identification of the procedures and their respective codes. The correct answer reflects the reporting of all distinct services. The calculation is conceptual, identifying the correct CPT codes for each distinct procedure performed: 1. Diagnostic Colonoscopy: 45378 2. Biopsy of Sigmoid Colon Lesion: 45380 3. Polypectomy of Transverse Colon Polyp: 45385 The correct coding approach involves reporting these distinct procedures. The explanation focuses on the rationale for reporting each code individually due to the distinct nature of the lesions and the procedures performed.

No calculation is required for this question as it assesses conceptual understanding of coding guidelines and clinical documentation. The scenario presented involves a patient undergoing a diagnostic colonoscopy with the identification and removal of a sessile polyp. The key to accurate coding lies in understanding the nuances of CPT coding for endoscopic procedures and the specific guidelines for polyp removal. A diagnostic colonoscopy is coded using CPT code 45378. When polyps are identified and removed during a diagnostic colonoscopy, the removal is considered an integral part of the diagnostic procedure, and no separate code for polyp removal is typically reported unless specific criteria are met, such as the polyp being unusually large or requiring extensive manipulation. However, the documentation indicates a standard sessile polyp removal. Furthermore, the National Correct Coding Initiative (NCCI) edits often bundle polyp removal into the diagnostic colonoscopy code when performed during the same encounter. Therefore, the most appropriate coding approach is to report the diagnostic colonoscopy with the appropriate ICD-10-CM diagnosis code for the polyp. The explanation of why other options are incorrect involves understanding that reporting a separate code for polyp removal (like 45385 for removal of a sessile polyp) without specific documentation justifying it as a distinct, complex service would be considered unbundling and a violation of coding guidelines. Similarly, reporting only the polyp removal code without the diagnostic colonoscopy code would be incorrect as the diagnostic procedure was performed. Finally, reporting a code for a different type of polyp removal or a more complex procedure without supporting documentation would also be erroneous. The focus for a Certified Gastroenterology Coder (CGIC) at Certified Gastroenterology Coder (CGIC) University is to adhere to payer policies and coding conventions, ensuring that services are accurately represented for reimbursement and compliance.

The scenario describes a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric polyp. The physician documents the procedure and the finding of a 1.5 cm sessile polyp in the gastric antrum, which was fully removed via hot snare polypectomy. The pathology report confirms the polyp is a hyperplastic polyp with no evidence of dysplasia or malignancy. To correctly code this encounter for Certified Gastroenterology Coder (CGIC) University standards, we must consider the CPT codes for the diagnostic procedure and the associated therapeutic intervention, as well as the ICD-10-CM code for the condition treated. The diagnostic EGD is coded using CPT code 43239 (Esophagogastroduodenoscopy, flexible, with biopsy, single or multiple). This code encompasses the visualization of the esophagus, stomach, and duodenum, and the taking of a biopsy. The removal of the gastric polyp via hot snare polypectomy is a therapeutic intervention performed during the EGD. While a biopsy was taken, the primary service performed was the removal of the polyp. CPT code 43254 (Esophagogastroduodenoscopy, flexible, with removal of foreign body or endoscopic stent, or with insertion of intraluminal device) is not appropriate as it describes removal of a foreign body or stent. CPT code 43255 (Esophagogastroduodenoscopy, flexible, with endoscopic mucosal resection (EMR)) is also not the most accurate, as EMR typically involves a more complex technique for removing larger or flatter lesions. The most appropriate code for the removal of a polyp via hot snare during an EGD is CPT code 43251 (Esophagogastroduodenoscopy, flexible, with ablation of tumor or other lesion, or with band ligation). This code accurately reflects the therapeutic removal of the polyp using a hot snare. The ICD-10-CM code for a hyperplastic polyp of the stomach, without mention of dysplasia or malignancy, is K31.7 (Polyp of stomach and duodenum). Therefore, the correct coding combination is CPT 43251 and ICD-10-CM K31.7. The explanation focuses on the distinction between diagnostic biopsy and therapeutic polyp removal, and the specific CPT codes that best represent the physician’s actions according to established coding guidelines relevant to advanced gastroenterology coding practices at Certified Gastroenterology Coder (CGIC) University. The emphasis is on understanding the nuances of procedure coding for endoscopic interventions.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, non-bleeding polyp. The physician also performs a separate, distinct diagnostic biopsy of a different, abnormal-appearing mucosal area in the sigmoid colon. For accurate coding at Certified Gastroenterology Coder (CGIC) University, understanding the nuances of reporting multiple procedures during a single encounter is crucial. The colonoscopy itself, including the visualization of the entire colon, is coded using a CPT code that reflects the diagnostic nature of the procedure. The removal of the polyp, a therapeutic intervention performed during the diagnostic exam, requires an additional code. Since the polyp was removed, the code for colonoscopy with polyp removal is appropriate. Furthermore, the separate diagnostic biopsy of the sigmoid colon represents a distinct service. This biopsy is not part of the polyp removal or the general diagnostic scope of the colonoscopy; it’s a targeted sampling of a different lesion. Therefore, it warrants its own CPT code. When multiple distinct procedures are performed during the same session, modifiers are often necessary to indicate this. However, in this specific instance, the CPT codes for colonoscopy with polyp removal and a separate diagnostic biopsy are inherently distinct and do not typically require a modifier to indicate that both were performed, as they represent separate actions. The key is to identify that the biopsy was of a *different* area and not intrinsically part of the polyp removal or the initial diagnostic scope. The correct coding approach involves identifying the primary procedure (colonoscopy with polyp removal) and then the secondary, distinct procedure (biopsy). The CPT codes for these services are selected based on the documentation of the procedures performed. The explanation focuses on the principle of coding each distinct service performed, which is a fundamental tenet of accurate gastroenterology coding taught at Certified Gastroenterology Coder (CGIC) University.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, sessile polyp in the sigmoid colon. The physician also performs a biopsy of a separate, visually distinct area of inflamed mucosa in the descending colon. For accurate coding at Certified Gastroenterology Coder (CGIC) University, understanding the distinct services rendered is paramount. The colonoscopy itself is coded based on the extent of the examination. The removal of a polyp, especially a sessile one, typically involves a specific CPT code that reflects the complexity of the polypectomy. The biopsy of the inflamed mucosa, even though performed during the same encounter and on the same organ, is a separate diagnostic procedure. Therefore, it requires its own distinct CPT code. When multiple distinct procedures are performed during the same session, modifiers are often necessary to indicate this. Specifically, a modifier such as 59 (Distinct Procedural Service) or its newer alternatives (like XE, XP, XS, XU) might be considered if the procedures are truly distinct and not bundled. However, the primary coding principle here is to identify each separately billable service. The colonoscopy with polyp removal is one service, and the biopsy of the inflamed mucosa is another. The question asks for the most appropriate coding approach, which involves assigning codes for each distinct procedure performed. The correct approach is to code the colonoscopy with polyp removal using the appropriate CPT code for the colonoscopy and the polypectomy, and then to code the biopsy of the inflamed mucosa using a separate CPT code for a biopsy of the colon. This reflects the comprehensive services provided and adheres to coding guidelines that prevent unbundling or incorrect reporting of services. The specific CPT codes would depend on the exact details of the polyp (size, morphology) and the biopsy technique, but the principle of separate coding for distinct procedures is the core concept being tested.

The scenario describes a patient undergoing a diagnostic colonoscopy with polyp removal. The physician documents a screening colonoscopy performed on a patient with a history of adenomatous polyps. During the procedure, a single sessile polyp, measuring 8 mm in diameter, is identified in the sigmoid colon and completely removed using hot snare cautery. The physician also documents the administration of moderate sedation. To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University’s rigorous academic standards, we must consider the primary reason for the encounter and the services performed. The patient is presenting for a screening colonoscopy, which is the overarching purpose. However, the identification and removal of a polyp transform the encounter into a diagnostic and therapeutic procedure. According to ICD-10-CM guidelines, when a screening colonoscopy leads to the discovery and removal of a lesion, the coding should reflect the diagnostic and therapeutic nature of the service. Therefore, the screening diagnosis code (Z12.11, Encounter for screening for malignant neoplasm of colon) is not the sole or primary code. Instead, the findings of the colonoscopy, specifically the polyp, and the procedure performed take precedence. For CPT coding, the base code for a colonoscopy with polyp removal is 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). The documentation specifies a sessile polyp removed by hot snare cautery, which aligns with this code. The moderate sedation is typically reported separately with code 00812 (Anesthesia for lower intestinal endoscopic procedures, including sigmoidoscopy and colonoscopy; with or without biopsy or local excision, or both). However, the question asks for the primary diagnosis and procedure coding, focusing on the physician’s work. Considering the history of adenomatous polyps and the removal of a new polyp, the most appropriate ICD-10-CM code for the diagnosis reflecting the physician’s action and the reason for the procedure’s complexity is K63.5 (Polyp of colon). This code accurately captures the finding that necessitated the intervention. The procedure code is 45385. Therefore, the correct coding combination reflects the diagnostic finding and the therapeutic intervention. The explanation focuses on the shift from screening to diagnostic/therapeutic based on findings and the specific CPT code for polyp removal via snare.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician documents the procedure as a “colonoscopy with sigmoid colon lesion biopsy.” According to standard coding guidelines for gastroenterology, when a diagnostic colonoscopy is performed and a lesion is identified and biopsied, the primary procedure code should reflect the diagnostic colonoscopy itself, and a separate code should be used for the biopsy. The CPT code for a diagnostic colonoscopy is 45378. The CPT code for a biopsy of the colon, performed during a colonoscopy, is 45380. When both a diagnostic procedure and a related therapeutic or diagnostic intervention (like a biopsy) are performed during the same session, it is crucial to understand how to report them to ensure accurate reimbursement and compliance with coding principles taught at Certified Gastroenterology Coder (CGIC) University. The National Correct Coding Initiative (NCCI) edits often bundle diagnostic procedures into more comprehensive procedures when performed together. However, for colonoscopies with biopsies, specific NCCI edits allow for separate reporting of the biopsy when it is performed on a distinct lesion. The key here is that the biopsy is performed on a *lesion*, indicating a specific target for the biopsy beyond just a general diagnostic sweep. Therefore, the correct coding approach involves reporting both the diagnostic colonoscopy and the biopsy. The explanation should focus on the rationale for reporting both codes, emphasizing the distinct nature of the diagnostic exploration and the targeted tissue sampling, which are fundamental concepts in CGIC curriculum for accurate procedure coding. The correct coding combination is 45378 and 45380.

The scenario describes a patient undergoing a diagnostic colonoscopy with polyp removal. The physician documents a screening colonoscopy performed on a patient with a personal history of adenomatous polyps, and during the procedure, a sessile polyp measuring 8 mm in the sigmoid colon is identified and removed via hot snare polypectomy. The physician also documents a separate, incidental finding of diverticulosis in the descending colon, for which no intervention is performed. To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, we must consider the primary reason for the encounter and the procedures performed. The patient’s history of adenomatous polyps makes this a follow-up examination, not a screening for a new patient. Therefore, the appropriate ICD-10-CM code for the encounter is Z86.010 (Personal history of polyps of digestive tract). The colonoscopy itself, performed for surveillance due to this history, is coded using the appropriate CPT code for diagnostic colonoscopy with biopsy/polypectomy. Given the identification and removal of an 8 mm polyp via hot snare, the CPT code 45385 (Colonoscopy, flexible, sigmoidoscopy, and proctosigmoidoscopy; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or electro-snare) is applicable. The diverticulosis, being an incidental finding without intervention, does not warrant a separate CPT code for treatment, nor does it change the primary diagnosis or procedure coding. The documentation supports the use of modifier -22 (Increased Procedural Services) if the polyp removal was unusually difficult or time-consuming, but without specific documentation of such, it is not applied. The focus is on the diagnostic intent and the therapeutic action taken for the identified polyp.

The scenario involves a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric polyp. The physician documents the procedure and the finding of a 1.5 cm sessile polyp in the gastric antrum, which was removed using hot snare cautery and sent for histopathology. The documentation also notes the absence of bleeding post-biopsy. To correctly code this encounter for Certified Gastroenterology Coder (CGIC) University standards, we need to identify the appropriate CPT codes for the EGD and the polyp removal. The EGD itself is coded using CPT code 43239 (Esophagogastroduodenoscopy, flexible, with biopsy, single or multiple). This code encompasses the diagnostic scope of the procedure and the inclusion of biopsy. The removal of the polyp using hot snare cautery is an integral part of the biopsy process when performed during an EGD and is not separately billable with an additional code in this context, as the biopsy code already accounts for tissue sampling. Therefore, the primary code for the procedure performed is 43239. The explanation focuses on the principle of “code bundling” and the specific guidelines for coding endoscopic procedures with biopsies and polyp excisions. For an EGD with biopsy, the single code 43239 accurately reflects the service. If a separate, more complex polyp excision technique were used that is not typically part of a standard biopsy, a different code might be considered, but hot snare cautery for polyp removal during an EGD is generally included within the biopsy code. The documentation supports the performance of a biopsy and the removal of the polyp, making 43239 the most appropriate and comprehensive code. The explanation emphasizes the importance of understanding CPT guidelines for endoscopic procedures, particularly regarding what services are bundled into specific codes, a core competency for CGIC professionals.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, non-pedunculated polyp. The physician documents the procedure as a “colonoscopy with polypectomy.” To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, one must consider the appropriate Current Procedural Terminology (CPT) codes. The primary procedure is the colonoscopy, which is coded based on whether it’s diagnostic or therapeutic. Since a polyp was removed, it is considered therapeutic. The CPT code for a colonoscopy with polyp removal is 45385. This code encompasses the visualization of the colon and the removal of the polyp. The documentation explicitly states a single polyp was removed, and no other significant findings or interventions requiring additional codes are mentioned. Therefore, the correct coding approach focuses on the most comprehensive code that accurately reflects the service provided. The explanation of why this code is selected involves understanding the hierarchy of CPT codes for endoscopic procedures and the specific descriptors that differentiate diagnostic scopes from those with interventions like polypectomy. The importance of precise documentation, as highlighted in the scenario, directly supports the selection of this specific code over a purely diagnostic colonoscopy code. This aligns with CGIC University’s emphasis on accurate representation of services rendered for proper reimbursement and quality reporting.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician’s documentation indicates the lesion was identified and a cold snare biopsy was performed. The pathology report confirms the presence of moderate dysplasia within the biopsied tissue. To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, one must consider the primary diagnostic procedure and any related therapeutic or diagnostic actions performed during the same session. The colonoscopy itself is coded using the appropriate CPT code for a diagnostic colonoscopy, which includes visualization of the entire colon. The identification and biopsy of a lesion are integral to the diagnostic process. However, when a lesion is identified and removed or biopsied, a separate CPT code may apply depending on the method of removal or biopsy. In this case, a cold snare biopsy is performed. The correct coding approach involves identifying the primary procedure (diagnostic colonoscopy) and then appending a code for the biopsy if it is separately reportable and distinct from the diagnostic intent. For a cold snare biopsy of a lesion identified during a colonoscopy, the appropriate CPT code reflects this specific action. The ICD-10-CM code would reflect the reason for the encounter, such as a screening colonoscopy with findings, or a follow-up examination with a specific condition. However, the question focuses on the procedure coding aspect. The CPT code for a colonoscopy with biopsy of a lesion is typically a combination of the colonoscopy code and a code for the biopsy technique. Given the scenario of a cold snare biopsy of a sigmoid colon lesion, the most appropriate CPT code reflects this specific intervention. The ICD-10-CM code for moderate dysplasia in the sigmoid colon would be a secondary code. The correct CPT code for a colonoscopy with biopsy of a lesion using a cold snare technique is 45385. This code specifically captures the performance of a colonoscopy with a biopsy using a forceps or snare technique. The ICD-10-CM code for moderate dysplasia of the colon is K63.5. Therefore, the primary procedure code is 45385.

The scenario describes a patient undergoing a diagnostic colonoscopy with the identification and removal of a single, sessile polyp in the sigmoid colon. The physician also performs a biopsy of a separate, visually distinct lesion in the transverse colon that appears inflammatory. For the polyp removal, the CPT code for colonoscopy with removal of a single lesion is 45385 (Colonoscopy, flexible, sigmoidoscopy and/or proctosigmoidoscopy; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Since only one polyp was removed, this code is appropriate. For the biopsy of the inflammatory lesion, the CPT code for colonoscopy with biopsy is 45380 (Colonoscopy, flexible, sigmoidoscopy and/or proctosigmoidoscopy; with biopsy, single or multiple). The fact that the lesion appears inflammatory does not change the coding for the biopsy itself; the physician is performing a biopsy of a lesion. When multiple distinct procedures are performed during the same session, the National Correct Coding Initiative (NCCI) guidelines and general coding principles dictate that the primary procedure is reported with its standard code, and any secondary procedures are reported with their respective codes, often with a modifier if applicable. In this case, both polyp removal and biopsy are distinct services. The colonoscopy itself is the base procedure. The removal of the polyp and the biopsy of the inflammatory lesion are separately reportable services performed during that colonoscopy. Therefore, the correct coding combination involves reporting both the polypectomy and the biopsy. The most accurate representation of these services is to report the colonoscopy with polyp removal and the colonoscopy with biopsy. The correct coding combination is CPT 45385 for the snare removal of the single polyp and CPT 45380 for the biopsy of the inflammatory lesion in the transverse colon. These codes accurately reflect the distinct procedures performed during the single colonoscopic encounter.

The scenario describes a patient undergoing a diagnostic colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician also performs a separate, unrelated polypectomy in the transverse colon. To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, one must consider the primary diagnostic procedure and any separately reportable services. The colonoscopy itself is coded using CPT code 45378 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without sigmoidoscopy, with or without colonoscopy, with or without examination of the ileum, with or without variable length enteroscope, and including examination of the ileum, with or without biopsy, single or multiple). The biopsy of the sigmoid colon lesion is an integral part of the diagnostic colonoscopy and is not separately billable when performed during the same encounter as the diagnostic procedure. However, the polypectomy in the transverse colon is a distinct therapeutic service performed during the same colonoscopy. According to CPT guidelines and common gastroenterology coding practices, when multiple distinct procedures are performed during a single endoscopic session, the primary procedure is reported with its full RVU, and subsequent, distinct procedures are reported with the appropriate CPT code and a modifier to indicate a reduced service or multiple procedures. In this case, the polypectomy in the transverse colon is coded with CPT code 45385 (Colonoscopy, flexible, sigmoidoscopy, flexible; with or without sigmoidoscopy, with or without colonoscopy, with or without examination of the ileum, with or without variable length enteroscope, and including examination of the ileum, with removal of a foreign body, with or without prophylaxis of bleeding, with or without biopsy, single or multiple, with removal of tumor(s), polyp(s), or other lesion(s) by snare, diaphoresis, or forceps). Since the polypectomy is a separate therapeutic intervention from the diagnostic biopsy, and both are performed during the same colonoscopy, the correct coding approach involves reporting the colonoscopy with biopsy (45378) and the polypectomy (45385) with modifier 59 (Distinct Procedural Service) or modifier XS (Separate Structure) if applicable under NCCI edits, to indicate that the polypectomy was a separate, distinct service from the diagnostic colonoscopy and biopsy. The question asks for the most appropriate coding *approach* for the *entire encounter*, considering the distinct nature of the polypectomy. Therefore, the correct approach involves reporting both the diagnostic colonoscopy with biopsy and the therapeutic polypectomy with appropriate modifiers to reflect the distinct services rendered. The value derived from this approach is the accurate reimbursement for both the diagnostic and therapeutic interventions, adhering to the principles of coding for distinct procedures as emphasized in CGIC University’s curriculum on CPT coding and modifier application.

The scenario involves a patient undergoing a diagnostic colonoscopy with the identification and removal of a sessile polyp in the sigmoid colon. The physician documents the procedure as a “colonoscopy with polypectomy.” To accurately code this encounter for Certified Gastroenterology Coder (CGIC) University standards, one must consider the primary reason for the encounter and the services performed. The colonoscopy itself is coded using CPT code 45385, which represents a colonoscopy with removal of a polyp, regardless of the method of removal (e.g., snare, forceps). The diagnosis code for the polyp, assuming it is a benign neoplastic polyp, would be K63.5. The documentation supports both the diagnostic and therapeutic aspects of the encounter. Therefore, the correct coding involves reporting the CPT code for the colonoscopy with polyp removal and the appropriate ICD-10-CM code for the polyp. The explanation focuses on the procedural coding for the colonoscopy with polyp removal, which is the core of the question. The selection of the correct CPT code hinges on identifying the most specific service performed, which in this case is the polypectomy during the colonoscopy. The rationale emphasizes the importance of linking the procedure to the diagnosis, a fundamental principle in gastroenterology coding at CGIC University.

The scenario describes a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric lesion. The physician documents the procedure, including the visualization of a 2 cm ulcerated lesion in the gastric antrum and the subsequent biopsy of this lesion. For accurate coding, the primary procedure is the EGD, which is coded using CPT code 43239 (Esophagogastroduodenoscopy, flexible, with biopsy, single or multiple). The documentation specifies a single biopsy. The diagnosis for the lesion, based on the physician’s initial assessment and the reason for the biopsy, would be coded using ICD-10-CM. Assuming the lesion is documented as a gastric ulcer, the appropriate ICD-10-CM code would be K29.5 (Gastric ulcer, unspecified, without hemorrhage or perforation). If the physician had documented a specific type of ulcer (e.g., K25.0 for acute gastric ulcer with hemorrhage), that would be used. However, based on the provided information, K29.5 is the most fitting code for an unspecified gastric ulcer requiring biopsy. The question asks for the most appropriate coding combination for the physician’s services. Therefore, the combination of CPT 43239 and ICD-10-CM K29.5 accurately reflects the procedure performed and the documented diagnosis. This approach ensures that both the service rendered and the underlying medical necessity are captured for billing and record-keeping purposes, aligning with the rigorous standards of Certified Gastroenterology Coder (CGIC) University’s curriculum which emphasizes precise documentation and coding accuracy. Understanding the nuances of lesion characterization and its impact on diagnostic coding is paramount for effective revenue cycle management and compliance.

The scenario describes a patient undergoing an esophagogastroduodenoscopy (EGD) with a biopsy of a gastric polyp. The physician documents the procedure, including the identification and removal of a 1.5 cm sessile polyp in the gastric antrum, followed by a biopsy of the polyp’s base for histological examination. The key to accurate coding lies in identifying the primary procedure and any distinct, separately reportable services. The EGD itself is coded based on the extent of the examination. The removal of the polyp, a polypectomy, is a distinct service that is separately reportable when performed during an EGD. The biopsy of the polyp’s base, while related to the polyp, is considered an integral part of the polypectomy in this context, as it’s performed to assess the removed tissue or the site from which it was removed. Therefore, the correct coding approach involves reporting the EGD with visualization and biopsy, and the polypectomy. Let’s break down the coding: 1. **EGD with biopsy:** The physician performs an EGD and takes a biopsy. This is coded using a CPT code that reflects the EGD service and the biopsy. 2. **Polypectomy:** The physician removes a polyp. This is coded using a CPT code for polypectomy during an EGD. When both an EGD with biopsy and a polypectomy are performed on the same lesion or at the same encounter, the coder must determine if the biopsy is bundled into the polypectomy or if it’s a separate service. In this case, the biopsy is of the polyp’s base, which is directly related to the polypectomy. Standard coding guidelines often bundle biopsies of the base of a lesion when the lesion itself is removed. However, the question implies a biopsy of the *base* of the polyp, which could be interpreted as a separate sample from the polyp itself or the underlying tissue. Given the common practice and coding conventions for EGDs, a biopsy of the polyp’s base is typically considered part of the polypectomy or the overall diagnostic workup of the polyp site. The primary services are the EGD and the polypectomy. The correct coding would involve a code for the EGD with biopsy and a code for the polypectomy. However, the question asks for the *most accurate* representation of the services performed, considering potential bundling. A common scenario is that the biopsy of the polyp’s base is integral to the polypectomy. Therefore, the most appropriate coding would reflect the EGD with visualization and the subsequent polypectomy. If a separate biopsy of a different site was performed, it would be coded separately. Here, the biopsy is of the polyp’s base, directly related to the removed polyp. Considering the options, the most accurate representation of the services performed, adhering to coding principles where biopsies of the base of a removed lesion are often bundled, would be to report the EGD with biopsy and the polypectomy. However, if the biopsy is considered a distinct diagnostic act from the removal itself, it would be coded. The scenario emphasizes the biopsy of the *base* of the polyp, suggesting an examination of the site after removal. Let’s re-evaluate the typical coding for this scenario. An EGD with biopsy is a specific code. A polypectomy during EGD is another specific code. When both are performed on the same lesion, the biopsy of the base of the polyp is often considered part of the polypectomy. However, some guidelines allow for separate coding if the biopsy is distinct. A more nuanced interpretation: The EGD is performed. A polyp is identified and removed (polypectomy). A biopsy of the *base* of the polyp is then taken. This implies the base itself was sampled. Let’s assume the CPT codes are: * EGD with biopsy: 43239 (Esophagogastroduodenoscopy, flexible, with biopsy, single or multiple specimens) * Polypectomy during EGD: 43250 (Esophagogastroduodenoscopy, flexible, with removal of tumor(s), polyp(s), or other lesion(s) by snare, cautery, or forceps) When both are performed on the same lesion, the biopsy of the base of the polyp is often considered integral to the polypectomy. However, if the biopsy is a separate specimen taken from the base *after* removal, it might be separately reportable. The most common and accurate coding practice for an EGD with polypectomy and a biopsy of the polyp’s base is to report the EGD with biopsy and the polypectomy. The biopsy of the base is often considered part of the polypectomy. Therefore, the most accurate coding would reflect the EGD with biopsy and the polypectomy. Let’s consider the specific wording: “biopsy of the polyp’s base.” This could be interpreted as a separate specimen from the polyp itself. The correct approach is to code the EGD with biopsy and the polypectomy. The biopsy of the polyp’s base is often considered integral to the polypectomy. However, if the biopsy is a distinct procedure from the removal, it would be coded. The most accurate coding would be to report the EGD with biopsy and the polypectomy. The biopsy of the polyp’s base is often considered part of the polypectomy. The correct answer reflects the EGD with biopsy and the polypectomy. Final Answer Calculation: The scenario involves an EGD with a biopsy and a polypectomy. The most accurate coding reflects both distinct procedures. EGD with biopsy: CPT code for EGD with biopsy. Polypectomy: CPT code for polypectomy during EGD. The biopsy of the polyp’s base is often considered integral to the polypectomy. Thus, the coding should reflect the EGD with biopsy and the polypectomy. The correct coding would be to report the EGD with biopsy and the polypectomy. The correct answer is the option that reflects the EGD with biopsy and the polypectomy.

The scenario describes a patient undergoing a colonoscopy with a biopsy of a suspicious lesion in the sigmoid colon. The physician documents “Sigmoid colon polyp, biopsy performed, benign findings.” For accurate coding at Certified Gastroenterology Coder (CGIC) University, understanding the interplay between diagnostic and procedural coding is paramount. The primary diagnosis for the encounter is the reason for the colonoscopy, which is the presence of the polyp. The ICD-10-CM code for a polyp of the colon, unspecified site, is K63.5. However, since the location is specified as the sigmoid colon, a more precise code is required. K63.5 is a general code for polyps of the colon. Given the documentation of a “sigmoid colon polyp,” the most appropriate ICD-10-CM code reflecting this finding, prior to definitive histological examination, would be K63.5 if no more specific site is available. However, if the documentation clearly states “sigmoid colon polyp,” a more specific code should be sought if available. In the absence of a more specific ICD-10-CM code for a sigmoid colon polyp that is not further specified as neoplastic or inflammatory, K63.5 remains the most appropriate general code for a polyp of the colon. The procedure performed is a colonoscopy with biopsy. The CPT code for a colonoscopy with biopsy of the colon is 45385. This code encompasses the visualization of the colon and the removal of tissue for pathological examination. The documentation supports both the diagnostic reason for the procedure (polyp) and the procedural service rendered (biopsy). Therefore, the correct coding combination involves identifying the most specific ICD-10-CM code for the polyp and the appropriate CPT code for the colonoscopy with biopsy. The explanation focuses on the selection of the correct ICD-10-CM code for the polyp and the CPT code for the biopsy procedure, emphasizing the importance of precise documentation for accurate coding in gastroenterology, a core competency at Certified Gastroenterology Coder (CGIC) University. The benign finding from the biopsy is crucial for subsequent coding and medical necessity justification but does not alter the initial diagnostic and procedural codes for this encounter.

The scenario involves a patient undergoing a diagnostic colonoscopy with the identification and removal of a sessile polyp in the sigmoid colon. The physician also performs a separate, distinct procedure to excise a pedunculated polyp from the transverse colon. For accurate coding, it’s crucial to understand the principles of coding for multiple procedures performed during a single session, particularly when they involve different anatomical locations and distinct techniques. The primary procedure is the colonoscopy with polyp removal. According to CPT guidelines, when multiple polyps are removed from different segments of the colon during a single colonoscopy, the coding should reflect the most complex polyp removal technique used. In this case, both polyps were removed, one sessile and one pedunculated. The removal of a sessile polyp often requires techniques like hot or cold biopsy forceps, or snare cautery, which are generally considered more involved than the removal of a pedunculated polyp, which might be removed with a simple snare. Therefore, the code for the more complex removal (sessile polyp) would be reported. However, the question specifies two distinct polyp removals from different anatomical locations (sigmoid and transverse colon). CPT guidelines for colonoscopy with polyp removal state that if multiple polyps are removed, the coder should report the code for the most complex polyp removal. If polyps are removed from different segments, and the documentation supports distinct procedures, modifiers may be necessary. In this specific instance, the removal of polyps from different segments of the colon during a single colonoscopy is typically reported with a single code for the most complex removal, with no additional codes for subsequent removals from different segments unless specific guidelines dictate otherwise. The key is that the base code for colonoscopy with polyp removal encompasses the removal of multiple polyps. The correct coding approach involves identifying the most complex polyp removal performed. The sessile polyp in the sigmoid colon, often requiring more precise technique for complete excision and potentially a higher risk of bleeding or perforation compared to a pedunculated polyp, would be considered the more complex removal. Therefore, the CPT code for colonoscopy with removal of a sessile polyp would be reported. The documentation supports the removal of both, but the coding convention for multiple polyp removals during a single encounter focuses on the most resource-intensive removal. The scenario does not involve separate diagnostic procedures or distinct therapeutic interventions that would warrant additional CPT codes beyond the primary colonoscopy with polyp removal. The focus is on the removal of polyps, and the coding should reflect the most comprehensive service provided for polyp excision. The correct answer reflects the CPT code for a colonoscopy with removal of a sessile polyp, as this represents the most complex polyp removal documented and performed during the single encounter. The fact that polyps were removed from different segments does not necessitate separate codes for each segment’s polyp removal when using the same colonoscope.