Gastroenterology Coding Alert

Question: A Medicare patient came in for a screening. The physician performed a cold biopsy on the transverse colon, and it appeared to be a polyp. Our pathologist indicated it was fecal matter. What diagnosis should I use?

Texas Subscriber

Answer: You should use 45380 (Colonoscopy ... with biopsy, single or multiple). Because you bill before the pathology results get back from the lab, you don't need to bother checking what the results are. You should rely on what the physician did rather than what the lab results indicated.