Two colon lesions, two techniques

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Medicare outpatient digestive professional service

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Indication and extent

Fictional outpatient, age 62, undergoes diagnostic colonoscopy for a documented change in bowel habits. The scope enters through the anus and reaches the cecum, identified by the appendiceal orifice and ileocecal valve. Preparation permits examination of the mucosa. No screening origin is documented.

Lesion map

A 4 mm lesion in the ascending colon is sampled with cold biopsy forceps. A separate 9 mm lesion in the sigmoid colon is completely removed with a cold snare. The physician explicitly identifies these as two distinct lesions. The scope report records the two techniques and sites; no other lesion is treated.

Completion and pathology

No bleeding-control intervention or additional therapeutic technique is performed. The patient tolerates the completed examination. Tissue is sent for pathology, which is pending at the time of this professional coding review. The coder must not infer adenoma or malignancy from appearance alone.

Work request

Review the completed endoscopic service or services using the authorized current book. Check the separate-lesion biopsy/removal relationship and the applicable edit before selecting any distinct-service modifier. Do not add a separate diagnostic colonoscopy simply because the procedure began with examination.

Your coding worksheet

Map site and technique for each lesion.
Investigate the complete procedure entries and current edit.
Explain why the same-lesion objection differs here.
State which diagnosis must await documented results.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The ascending lesion is biopsied and a distinct sigmoid lesion is removed by snare.
NCCI H.25 supports reviewing the separate-lesion exception; verify the current entries, edit and modifier conditions before final reporting.
The diagnostic examination is included in surgical endoscopy. Distinct lesions, not instrument or container count alone, support the relationship.
Pathology is pending. Do not invent the histology or malignancy; follow the documented findings and outpatient diagnosis rules.

Reference sections: H.25

Practice the linked chart questions