Wiki Discrepancy/Contradiction

[rwinkfield@tds.net]

I'm looking for advice on what to do about the following problem:

The Dr. performs a Colonoscopy, finds 2 polyps, Hepatic Flexure, Snares them, sends to Pathology. Finds 3 tiny polyps in the rectum and destroys them.
Path report comes back with report on the specimens: 2 HF polyps ("tubular adenomas (2)"), AND "Rectal polyp: Hyperplastic Polyp."
I polled the Dr. again and he was emphatic that he destroyed all 3 tiny rectal polyps. I went to pathology and they faxed the requisition, showing 2 containers, the first w/ the HF specimens and the second container labeled w/ Pt's name and "Rectum," which they rechecked to confirm the label.

Not sure what to do next coding-wise. It does not affect ICD-9 coding, but does affect the Px code(s) attached to the CPT code 45385 for the snare.

And do I pursue the discrepancies to resolve the problem generated by the 2 seemingly contradictory reports?

 

[cathy@eyebillforyou.com]

I think bill what the doctors says he/she did. I have the dr sign off and/or correct the path report that comes back and ends up in the file. Leave it at that. If he corrects the path report I would send a copy back to them and keep the other one in our file.