I’ve a case where the encounter is for screening colonoscopy (ICD-10-CM: Z12.11). The surgeon found a polyp (ICD-10-CM: K63.5) in the transverse colon and excised it using snare (CPT 45385). Pathology report comes a few days later and states the excised tissue as "normal colonic mucosa".

Did the surgeon excised normal tissue only and if that is the case what would be the codes? Should we code for biopsy only and not snare since there was no lesion that was excised and was rather normal tissue?

I’ve narrowed it down to:

1. ICD-10-CM: Z12.11, K63.5; CPT: 45385; OR
2. ICD-10-CM: Z12.11; CPT: 45380

Any insights?

Thanks!

Amber