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Screening Colonoscopy with Random Biopsy

  1. Default Screening Colonoscopy with Random Biopsy
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    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.

  2. #2
    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.

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