Colonoscopy - Biopsy, then fulguration

LindsayC

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I have a DR who does a lot of colonoscopy's. I have been coding them for about 6 months, but am now training another individual, so I am second guessing a couple things. All help would be appreciated.

Dr states: "In the mid rectum, she had 3-4 small polyps the I cold biopsy x2 and then fulgurated the rest of them to the base."

Do we code 45380 or code 45388?
 

rbandaru

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Hello,

45385 and 45380-59 to be coded. Here biopsy for two lesions (45380) and polypectomy for two lesions (45385) with a modifier 59 for lesser value.
If biopsy and polypectomy is done for all the lesions only 45385 would be sufficient with no 45380 biopsy includes in polypectomy of the same lesions.

Regards
Dr.Ramnath Bandaru, CCS, CPC
American Medical Services LLC
http://amshealth.com/
Twitter:mad:HospitalCoders
 
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