ksschroeder
Networker
Good Morning. Ideally, I am seeking official AMA references in answering this question, but any expert opinions you have are also welcomed...If a GI physician performs and bills a colonoscopy in which a biopsy is obtained (45380) and the professional component of interpreting and reporting on that biopsy specimen itself is billed by an external pathologist, can the GI physician get E/M data element credit for reviewing the pathologists report in the subsequent E/M visit? Or, would it be considered double dipping, because the review of pathology is inherent to the procedure and included in the professional component of the colonoscopy he performed and billed? Or, is there another option I haven't thought of yet 
? Thank you for any official source information you can provide. Here is an example of the documentation. This patient has a commercial insurance and is in 2025 in for evaluation of surveillance colonoscopy due to PMH adenomatous polyps. This same physician has performed all of the colonoscopies mentioned in the following documentation example:
"This is a 58 year old male who is her for evaluation for colonoscopy given his prior history of c colonic adenomas. He has a bowel movement once to twice daily with formed stool. There is no melena or hematochezia. He denies abdominal pain, nausea, vomiting or weight loss. There is no family history of colon cancer. He denies any heartburn, dysphagia or odynophagia. He did have a colonoscopy in 2009 and again in 2014 and revealed diverticulosis and polyps which were tubular adenomas on pathology. A colonoscopy in 2020 revealed only diverticulosis. I reviewed all pathology reports."
? Thank you for any official source information you can provide. Here is an example of the documentation. This patient has a commercial insurance and is in 2025 in for evaluation of surveillance colonoscopy due to PMH adenomatous polyps. This same physician has performed all of the colonoscopies mentioned in the following documentation example:"This is a 58 year old male who is her for evaluation for colonoscopy given his prior history of c colonic adenomas. He has a bowel movement once to twice daily with formed stool. There is no melena or hematochezia. He denies abdominal pain, nausea, vomiting or weight loss. There is no family history of colon cancer. He denies any heartburn, dysphagia or odynophagia. He did have a colonoscopy in 2009 and again in 2014 and revealed diverticulosis and polyps which were tubular adenomas on pathology. A colonoscopy in 2020 revealed only diverticulosis. I reviewed all pathology reports."