In our office, we bill both the office visit and the colposcopy (57456) using the diagnosis from the pathology report, if dysplasia is found. I was always taught to code what you know at the end of the visit. If the pathology report comes back without any additional findings, we go back to the specific code from the most recent pap smear, ASCUS, LGSIL, etc. You are correct to use the 25 modifier on the office visit, although we don't always charge the office visit in addition to the procedure, if it was our physician who obtained the abnormal pap smear at a fairly recent visit. I would be interested to hear if anyone else does anything different. Thanks!
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