Colonoscopy with sigmoid polypectomy and submucusal injection

The patient underwent colonopscopic removal of sigmoid polyps with snare technique with submucusal injection. The procedure was carried out in ambulatory setting. Pathological finding revealed cancer of sigmoid colon. What are the ICD and CPT codes for these services?


1        153.3         Malignant Neoplasm of Sigmoid Colon

PX      CODE      DESCRIPTION         

1         45.42        Endoscopic polypectomy of large intestine
2        99.29         Infusion of substance (Submucusal injection)         

CPT   CODE      DESCRIPTION             
1        45385       Colonoscopic polypectomy with snare technique
2        45381       Flexible colonoscopy with Submucusal injection

Although the preop diagnosis is colon polyp, the primary diagnosis is sigmoid cancer as the pathologic finding revealed cancer. In ambulatory surgery coding pathologic finding can be taken as primary diagnosis. Submucocal injection are also sometimes referred as tattoing.

Sometimes patients come for just screening and a polyp may be found and removed during the colonoscopy.  In such scenarios, primary diagnosis and secondary diagnosis should be as follows:


V76.51           Screening for malignant neoplasm of colon

211.3/211.4    Polyp of colon

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