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Screening w/biopsy w/no findings

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rebelhotspur

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9
Location
Galloway, NJ
Getting a Medicare denial for a screening with biopsy 45380 PT with no pathological findings. How do I rectify this? Add K63.89 as secondary diagnosis?
 
Hi rebelhotspur,
I am a little confused - was this for a screening (initial post) or was it because of the microscopic colitis (third post)? If a patient comes into the facility for a procedure and there is nothing documented in the GI surgical report and nothing indicated (no abnormality) in the pathology report - you would code the reason why the procedure was performed (the indication). No, absolutely do not add K63.89 other specified diseases of the intestine to something you are stating (in your first post) had no pathological findings. I don't know if that is truly the case or not in this scenario, but I am a pathology coder and would be willing to help and take a peek at the pathology report if you wanted to share for another opinion (without PHI of course)?
Please reach out if you need assistance and have a great evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
Thank you, Dana. It was initially a screening and the physician took random biopsies based on what he saw during the procedure, making it therapeutic. We used 45380 (PT) Z1211, K648.
 
You are talking about the procedure denying, correct? Not pathology?
So if he saw something that warranted a biopsy but the pathology revealed no findings, it would be appropriate to code based on what he saw/found. Something 'funny looking' or abnormal condition of the intestine - K63.89.
If he took biopsies due to diarrhea then I would code that.
 
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