A patient is seen in the outpatient clinic for a colonoscopy due to a family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by hot biopsy forceps. What should the CPT and diagnosis codes for this case be?

Question

Quizplus · Accepted Answer

The correct CPT code for a colonoscopy with removal of a polyp by hot biopsy forceps is 45384. The diagnosis codes should be ordered as follows: Z12.11 (screening for malignant neoplasm of colon due to family history), Z80.0 (family history of malignant neoplasm of digestive organs), and K63.5 (polyp of colon). This order prioritizes the reason for the encounter (screening) followed by the family history that prompted the screening and the finding of the polyp.

A Patient Is Seen in the Outpatient Clinic for a Colonoscopy