Which combination of codes would be appropriate for a colonoscopy with normal mucosa and rectal biopsies?

Which combination of codes would be appropriate for a colonoscopy with normal mucosa and rectal biopsies?

• A. Z85.01, 45380
• B. Z85.00, 45381
• C. Z85.00, 45370
• D. Z85.00, 45380

Answer: (D)

The key idea here is pairing the correct procedural code with a secondary diagnosis that reflects the patient’s history when appropriate. A colonoscopy performed with biopsies, even when the mucosa appears normal, is coded as a colonoscopy with biopsy. The CPT code that represents this scenario (colonoscopy, diagnostic, with biopsy) is 45380. Since the chart indicates a personal history of malignant neoplasm, a Z-code should be added to document that history on the claim; the appropriate choice among the options is Z85.00 (personal history of malignant neoplasm). The other CPT options would imply different procedures (such as polypectomy or additional interventions) and aren’t indicated by “colonoscopy with normal mucosa and rectal biopsies.”

The key idea here is pairing the correct procedural code with a secondary diagnosis that reflects the patient’s history when appropriate. A colonoscopy performed with biopsies, even when the mucosa appears normal, is coded as a colonoscopy with biopsy. The CPT code that represents this scenario (colonoscopy, diagnostic, with biopsy) is 45380. Since the chart indicates a personal history of malignant neoplasm, a Z-code should be added to document that history on the claim; the appropriate choice among the options is Z85.00 (personal history of malignant neoplasm). The other CPT options would imply different procedures (such as polypectomy or additional interventions) and aren’t indicated by “colonoscopy with normal mucosa and rectal biopsies.”