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A 67-year-old male patient with a history of carcinoma of the sigmoid colon is referred for a diagnostic colorectal cancer screening. The physician performed a diagnostic flex sigmoidoscopy exam to screen for recurrent colon cancer and examine the anatomic site. During the exam, the physician found three polyps in the rectosigmoid junction. They were removed by hot biopsy forceps. The path report indicated the polyps were benign. Code the encounter.

A) 45338
B 45331
C) 45339
D) 45333

1 Answer

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Final answer:

The correct medical procedure code for a diagnostic flex sigmoidoscopy with removal of polyps by hot biopsy forceps is 45338. This code reflects the services performed regardless of the benign nature of the polyps removed.

Step-by-step explanation:

In coding a medical procedure such as the one described, it is essential to select the code that accurately reflects the services performed. The patient underwent a diagnostic flex sigmoidoscopy with removal of three polyps by hot biopsy forceps. After assessing the options provided (A:45338, B:45331, C:45339, D:45333), the correct code for this scenario would be 45338, which relates to a sigmoidoscopy with the removal of polyps or other lesions by hot biopsy forceps.

It is important to note that while the path report indicated the polyps were benign, this fact does not influence the selection of the procedural code. The coding is based on the procedure performed, which in this case involved both examination and removal of polyps.

Screening for colorectal cancer is recommended for those over 50 years of age and can include tests such as fecal occult blood tests and colonoscopies. A colonoscopy is the gold standard for diagnosing colorectal cancer because it not only detects it but can also help in its prevention by enabling the removal of potentially pre-cancerous polyps. Diagnosis and treatment of colorectal conditions are paramount for patient health, and proper coding is vital for accurate healthcare record-keeping and billing.

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