Wiki Screening Colonoscopy with Random Biopsy

[jmddwilson]

Medicare patient in for screening colonoscopy, the physician documents doing a random biopsy that came back as benign mucosa.

Am I correct in thinking that this should still be coded as G0121? A "diagnostic colonoscopy with biopsy (45380)" is finding a lesion or polyp to biopsy for diagnostic reasons. Since there is no reason, but "random" biopsy, there is nothing to lead me to diagnostic. Therefore, still screening?

Thank you in advance.

 

[MarylouT]

Without benefit of seeing the colonoscopy report, I would use 45380. If the physician performed a biopsy during the course of a screening colonoscopy, you would code 45380 but add PT modifier. If he did a biopsy, he was looking for something.

 

[ssb2003]

Hello, My question is about what ICD to use in this case, The doctor reports "No ulcerations, No polyps, no diverticulosis noted. Biopsies were obtained from ascending colon, transverse colon, descending colon, sigmoid colon and rectum Using cold forceps biopsy and sent for pathology." It's screening, so should I use 45380, PT, Z12.11,,, any other Dx? for the random biopsies? When labs reports no abnormalities

 

[b_lep]

If the path report didn't find anything and the biopsies were just random then yes, you'd just use Z12.11 for the dx.