Documentation questions...HELP

[songbird4700]

We are having a highly spirited debate at my office regarding the documentation of a 45380...
AND of 45378 vs HCPCS codes.

I would love to hear any and all comments regarding this.

Here is the scenario #1

Patient is seen for a colonoscopy, a polyp is found and removed. The problem lies in the physician's documentation of the removal. He indicated that the polyp was removed via "biopsy forceps". Would you immediately code as a 45380? Or would you question the physician, asking whether or not the forceps used were hot or cold?

Scenario #2

Medicare patient is seen for colonoscopy with an indication of V12.72, personal history of polyps. No polyps, masses, or lesions are found. Is this coded as a G0105, high risk screening? Or, because the actual term "screening colonoscopy" is never mentioned, would it be coded as a 45378?

Please, any comments AND back up documentation would be greatly appreciated!!

 

[scorrado]

#1 - I would ask the doctor what he means. I have a doctor that always puts on his billing card "polypectomy" which to him means snare. (he is more specific in his op note). If his op notes isn't specific that could be a problem. My first instinct would be to bill 45380.

#2 - I would bill G0105. V1272 is a code that Medicare specifies as being high risk and should be billed with the high risk screeing code - G0105.

Hope this helps!

 

[sleepycats]

We are having a highly spirited debate at my office regarding the documentation of a 45380...
AND of 45378 vs HCPCS codes.

I would love to hear any and all comments regarding this.

Here is the scenario #1

Patient is seen for a colonoscopy, a polyp is found and removed. The problem lies in the physician's documentation of the removal. He indicated that the polyp was removed via "biopsy forceps". Would you immediately code as a 45380? Or would you question the physician, asking whether or not the forceps used were hot or cold?

Scenario #2

Medicare patient is seen for colonoscopy with an indication of V12.72, personal history of polyps. No polyps, masses, or lesions are found. Is this coded as a G0105, high risk screening? Or, because the actual term "screening colonoscopy" is never mentioned, would it be coded as a 45378?

Please, any comments AND back up documentation would be greatly appreciated!!

Scenario #1-I would query the MD for type of forceps used, hot or cold, since this does affect the code selection.
Scenario #2-If the patient had no signs or symptoms I would code G0105 even if it's not stated as a screening. If anemia, change in bowel habits, etc. is mentioned I would code 45378.