Wiki Billing procedure when path specimen is lost

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SandyToes84

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My practice manager wanted me to clarify a coding issue. Our physician performed an EGD with a biopsy of the esophagus. When the specimen container arrived at the pathologist's office, there was no specimen in the container. For our physician's services, I billed an EGD with biopsy but she questions this as there is no pathology to verify that the biopsy was done. Can you shed some light on this situation from an auditor's point of view? I believe we bill for what our physician did and the events that happened afterward are irrelevant to my procedure code. Should I have somehow made a note to the effect that there was no specimen that arrived at the pathologists? Please advise.
 
If the OP report states the method, location, etc of the biopsy, then you would have no trouble billing for the biopsy. I am guessing that the lab sent you a report that says the container was received, but no specimen was found. Keep a copy of that in the patient's file and you should be fine.
 
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