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Wiki Colonoscopy with cautery of AVM

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frankpope

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Patient has a colonoscopy and the doctor discovers an AVM in the colon. He performs cautery. However, there is no documentation that the AVM is actively bleeding or that it was bleeding previously. Do I still use 45382 for "control of bleeding"? Maybe I'm thinking too much into this. Do doctors cauterize it to prevent future bleeding?
 
You will use 45382 or 45388 depending on the intent. Was it for control of bleeding or destruction/ablation? You may have to query the provider for the reason. It does not have to be actively bleeding in order for it to be control of bleeding. It can be for prevention as well.
 
clarkmegan said:
You will use 45382 or 45388 depending on the intent. Was it for control of bleeding or destruction/ablation? You may have to query the provider for the reason. It does not have to be actively bleeding in order for it to be control of bleeding. It can be for prevention as well.
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Do you have a resource supporting code selection of "control of bleeding" when there is not active bleeding? I have been searching for this but haven't found it, yet. Thanks!
 
jek521 said:
Do you have a resource supporting code selection of "control of bleeding" when there is not active bleeding? I have been searching for this but haven't found it, yet. Thanks!
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It was in a webinar. I cannot put my hands on the source quickly, but usually if a patient has iron deficiency anemia, that would justify medical necessity. Also, even though it is not currently bleeding, it does not negate that the fact that AVM/ulcer/etc. was the previous source of bleeding. Try searching CMS or coding clinics. as well
 
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