Looking for some opinions or further information on this scenario:
OPERATION: Colonoscopy w/ polypectomy of a sigmoid colon polyp and biopsy of the cecum
Physician does not state any further information on polypectomy other than "polypectomy was performed and polyp was removed in its entirety" and biopsy says "cecal mass found and we proceeded with multiple biopsies of this".
The CPTs used in the above scenario were:
45388 and 45380
When the physician billed out for his portion, he used 45385 - snare technique
If this was truly snare technique, he will need to addend his OP report, this I know.
My question is if he does addend to say snare for polyp, do I use 45385? What do I do with the cecum bx? The physician is telling me that you can never put 45388 and 45380 together on a claim and that they are both included in 45385.
Any help with this would be greatly appreciated....I am just trying to figure out if this is a coding issue or a physician documentation issue.
OPERATION: Colonoscopy w/ polypectomy of a sigmoid colon polyp and biopsy of the cecum
Physician does not state any further information on polypectomy other than "polypectomy was performed and polyp was removed in its entirety" and biopsy says "cecal mass found and we proceeded with multiple biopsies of this".
The CPTs used in the above scenario were:
45388 and 45380
When the physician billed out for his portion, he used 45385 - snare technique
If this was truly snare technique, he will need to addend his OP report, this I know.
My question is if he does addend to say snare for polyp, do I use 45385? What do I do with the cecum bx? The physician is telling me that you can never put 45388 and 45380 together on a claim and that they are both included in 45385.
Any help with this would be greatly appreciated....I am just trying to figure out if this is a coding issue or a physician documentation issue.
