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Wiki Colonoscopy -few general surgeons

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dltdavis

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Hi I am coding for a few general surgeons that perform Colonoscopies. I have the question of when to use the 45380 vs 45384. My docs likes to use the phase "biospy optained by forceps". I want to use 45380 because I do not see anywhere in the op note "hot" or bipolar cautery. A senior coder here said no to use the 45384.

So I am looking for some guidance as to where I can find this information.

thank you to anyone who can help me.
 
Colonoscopy

if they do not specify, always use the cold bx (45380) because that is normally the way they do it
 
Use 45380 unless they specify hot or cautery. I was at the coding con conference in Dec and this is how we are directed if they don't say it in the op note.
 
I agree w/ both sferguson & cooper1, if it doesn't specifically mention hot/cautery, then use 45380. same goes w/ cold. if those words are not mentioned, go w/ 45380.
 
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