45382 Or 45383


Branford, CT
Best answers
Operative note states..."In the distal rectum, there were telangectasias with oozing consistent with the patient's history of radiation proctitis. This was treated with Argon Plasma Coagulation."

Physician believes we should bill 45382 (Control of Bleeding) I think we should bill 45383 (with ablation of tumor(s), polyp(s) or other lesions...)

Any input?
Its hard to answer that without seeing the entire op report but from what I see I believe that I would code 45382.
I work for a Gastroenterologist and we would actually use both with a 59 modifier or for some carriers 51, if the doctor found polyps as well as the bleeding. It seems as though he did parts of both procedures. Does his notes state that he did? Did he find any polyps? If he didn't find any polyps than the control of bleeding code would be more appropriate, if nothing else was found or documented. Hope this gives you an idea.

Felicia Copeny, CPC-A
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re: proper code usage

Yes 45382 would be used because in the report it mentioned treated for coagulation.. To use the other code the report would definately state abalation, good luck.
control of bleed

APC is the method used to control bleed
since there is an active bleeding site, use the control of bleed.
If there is no active bleeding site, pt had prior bleed,
you would code for ablation.