Lesion Removed During Endoscopy

Lesion Removed During Endoscopy

Test your skills with a new coding question from Clinical Coding Workout every Monday.

When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure?

Source: AHIMA Press. Clinical Coding Workout, 2019. https://my.ahima.org/store/product?id=65592.

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  1. Can’t make assumptions, must query the physician.

  2. I like to think this has not changed since my days of coding in ICD-9–The physician needs to be asked how the lesion was removed. NEVER ASSUME!!

  3. yes thanks,
    you need this information to even start your procedure coding

  4. None of the options can be selected unless physician specifies , and to get the correct root operation Physician must specify if a lesion is removed/destroyed.

  5. not appropriate for the coding professional to assume that the removal was done by either snare or hot biopsy forceps. The ablation code is only assigned when a lesion is destroyed, and no specimen is retrieved. The coding professional must query the physician to assign the appropriate code.

    1. Good knowledge, it helps me to prepare for my cpc exam

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