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

CPT code 45384 is correct for a colonoscopy with removal of a polyp by hot biopsy forceps. The diagnosis codes are correctly ordered with Z12.11 (encounter for screening for malignant neoplasm of colon) as the primary reason for the encounter, followed by Z80.0 (family history of malignant neoplasm of digestive organs) for the family history of colon cancer, and K63.5 (polyp of colon) for the finding during the procedure.

A Patient Is Seen in the Outpatient Clinic for a Colonoscopy