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So my doc seen a pt, GI bleed with BRBPR and decided to perform a Colonoscopy.
Doc performed a Colonoscopy to the cucum, took biopsies in other areas of the colon, but my major concern is the APC cauterization performed on telangiectasias in the rectum. The was NO ACTIVE BLEEDING, rather this is the suspected site of bleeding and so he cauterized the lesion.
The CPT 2017 does not mention bleeding has to be active, 45382 just says "with control of bleeding, any method". 45388 specifies "with ablation...", however my DR did not use ablation, his method was cauterization.
A) Can I code the control of bleed WITHOUT active bleeding, simply because this is the suspected site??
B) If so, is this only due to the telangiectasias in this particular case??
C) What if it were AVMs, not actively bleeding at that moment, and were the suspected point of bleeding??
Any advice is welcome ...include your sources if you could too please.
THANK YOU!!!
Doc performed a Colonoscopy to the cucum, took biopsies in other areas of the colon, but my major concern is the APC cauterization performed on telangiectasias in the rectum. The was NO ACTIVE BLEEDING, rather this is the suspected site of bleeding and so he cauterized the lesion.
The CPT 2017 does not mention bleeding has to be active, 45382 just says "with control of bleeding, any method". 45388 specifies "with ablation...", however my DR did not use ablation, his method was cauterization.
A) Can I code the control of bleed WITHOUT active bleeding, simply because this is the suspected site??
B) If so, is this only due to the telangiectasias in this particular case??
C) What if it were AVMs, not actively bleeding at that moment, and were the suspected point of bleeding??
Any advice is welcome ...include your sources if you could too please.
THANK YOU!!!