Wiki Colonoscopy -few general surgeons

[dltdavis]

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.

 

[sferguson]

Colonoscopy

if they do not specify, always use the cold bx (45380) because that is normally the way they do it

 

[cooper1]

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.

 

[dolly_deleon]

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.