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45385 & 45380 for random biopsies

C

crumes

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North Olmsted, OH
Is it acceptable to bill for 45385 for a snare and 45380 for random biopsies to rule out microscopic colitis? The op notes only specify the right and left of colon with no notation of a different technique being utilized.
 
If it's not documented, it didn't happen!!

Unfortunately, you cannot guess as to which methods the physician performed. The op note must state what method was used for taking biopsies and from what location.
Without this you cannot bill this with biopsies.

For example, "multiple cold forceps biopsies were taken from the hepatic flexure, splenic flexure and the sigmoid colon."
In this example all you can report is 45380.

If the notes states "biopsy obtained from the hepatic flexure polyp via snare technique as well as cold forceps biopsy taken of the sigmoid colon." With this example you get to bill 45385 & 45380-59

You only get to bill a separate method if it is performed at a completely different location than where the other method was performed.

Caprice Walder, CPC
 
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