CPT Code 45380

BKDaniels

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Hi :)
I have a coder receiving an edit in the grouper that we are exceeding our units of 45380. She coded the below op report with 45380, 45380-59 to indicate the separate biopsy sites. Can anyone tell me why this isn't justified?

Examination of the perianal region was normal. Rectal exam unremarkable. The
Olympus PF-190L videocolonoscope was inserted into the rectum and advanced to
the cecum as well as distal TI with good visualization throughout. The patient
having a 0.5 cm polyp cold biopsy removed in the transverse colon with localized
superficial erythema in the cecum, biopsies of which were taken, path is
pending. Patient had a 0.5 cm polyp, cold biopsy removed the ascending colon.
There was mild left-sided diverticular disease. The remaining colon, rectum to
cecum including ileocecal valve and distal TI was otherwise unremarkable. Bowel
was decompressed. The scope was withdrawn. The patient tolerated the procedure
well.

IMPRESSION:
1. Status post 0.5 cm polyp cold biopsy removed in the transverse colon. Path
is pending.
2. Status post biopsies of cecal erythema. Biopsies taken, path is pending.
3. Status post 0.5 cm polyp cold biopsy removed in the proximal ascending colon
with the remaining colon, rectum to cecum otherwise unremarkable.

PLAN:
Recommend the patient avoid salicylates, nonsteroidals x1 week. We will check
the path report, depending on the findings we would make further
recommendations.

Thank you!!
 

CodingKing

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Code description is single or multiple so it should never be reported more than once per encounter no matter how many biopsies are done.
 
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