Screening colonoscopy with one sigmoid polyp removed

Screening history

Fictional patient Alma Reed, age 68, presents for an average-risk colorectal cancer screening colonoscopy. She reports no rectal bleeding, anemia, bowel change, unexplained weight loss or abdominal pain. There is no personal history of colorectal neoplasia and no relevant family history. This is not a follow-on colonoscopy after a positive stool or blood-based screening test. The packet states that applicable Medicare screening eligibility and frequency requirements are met.

Procedure preparation and extent

The gastroenterologist confirms the screening purpose and obtains consent. Bowel preparation is adequate. The colonoscope is advanced through the colon to the cecum, identified by the documented landmarks, and the mucosa is examined during withdrawal. There is no incomplete or discontinued examination. An independently reporting anesthesia professional manages sedation; the gastroenterologist does not provide a separate moderate-sedation service.

Polyp technique

One 6 mm sessile polyp is found in the sigmoid colon. The endoscopist takes a small cold-forceps tissue sample from that lesion and then removes the same lesion completely with a cold snare. Both samples are labeled as portions of the same sigmoid polyp. No separate lesion is biopsied and no second polyp is removed. There is no separately treated bleeding site, dilation, ablation or other therapeutic intervention.

Final documentation

The pathology report identifies a tubular adenoma without high-grade dysplasia or malignancy. The endoscopist reviews the result and signs the final diagnosis as benign adenoma of the sigmoid colon. The record is complete before the coding exercise. The patient receives the procedure findings and routine discharge and follow-up instructions; no unrelated separate E/M problem is evaluated on the procedure date.

Professional coding request

Prepare the endoscopist’s claim reasoning for the completed service. Address the original screening purpose, the discovered diagnosis, the actual snare removal and the same-polyp forceps sampling. The draft contains the original screening-only procedure, a snare procedure and a separate biopsy with a distinct-service modifier. Determine which service relationship is supported and whether the Medicare screening-conversion modifier applies. Do not report the anesthesia professional’s work as the endoscopist’s service.

Your coding worksheet

1. Identify the reason for this encounter and the supported diagnoses.
2. List the services actually completed and the applicable code sets.
3. Use your books to select final codes, units and any supported modifiers.
4. Sequence the diagnoses and explain the relevant instruction.
5. Review included work and any separate coverage question. Explain why the strongest alternative does not fit.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.