During a colonoscopy with biopsies, the impression is normal colon mucosa. Which codes should be used?

During a colonoscopy with biopsies, the impression is normal colon mucosa. Which codes should be used?

• A. Z85.00 45380
• B. Z85.00 45381
• C. Z85.00
• D. 45380 Z85.00

Answer: (A)

During a colonoscopy that includes biopsies, you code the procedure with the CPT for a colonoscopy with biopsy and accompany it with the appropriate ICD-10-CM diagnosis. The base procedure code is 45380, which covers a colonoscopy with biopsy; 45381 would be used only if there are additional biopsies beyond the first. The diagnosis code should reflect the patient’s condition or history relevant to the procedure; if there is a history of colon cancer, that is documented with Z85.00, making the combination of Z85.00 and 45380 appropriate. The order shown (diagnosis before the procedure) follows typical outpatient coding practice, and the normal mucosa finding affects interpretation but does not require a different base procedure code. Therefore, pairing Z85.00 with 45380 is the correct approach.

During a colonoscopy that includes biopsies, you code the procedure with the CPT for a colonoscopy with biopsy and accompany it with the appropriate ICD-10-CM diagnosis. The base procedure code is 45380, which covers a colonoscopy with biopsy; 45381 would be used only if there are additional biopsies beyond the first. The diagnosis code should reflect the patient’s condition or history relevant to the procedure; if there is a history of colon cancer, that is documented with Z85.00, making the combination of Z85.00 and 45380 appropriate. The order shown (diagnosis before the procedure) follows typical outpatient coding practice, and the normal mucosa finding affects interpretation but does not require a different base procedure code. Therefore, pairing Z85.00 with 45380 is the correct approach.