Results 1 to 3 of 3

Documentation questions...HELP

  1. #1
    Question Documentation questions...HELP
    Medical Coding Books
    We are having a highly spirited debate at my office regarding the documentation of a 45380...
    AND of 45378 vs HCPCS codes.

    I would love to hear any and all comments regarding this.

    Here is the scenario #1

    Patient is seen for a colonoscopy, a polyp is found and removed. The problem lies in the physician's documentation of the removal. He indicated that the polyp was removed via "biopsy forceps". Would you immediately code as a 45380? Or would you question the physician, asking whether or not the forceps used were hot or cold?

    Scenario #2

    Medicare patient is seen for colonoscopy with an indication of V12.72, personal history of polyps. No polyps, masses, or lesions are found. Is this coded as a G0105, high risk screening? Or, because the actual term "screening colonoscopy" is never mentioned, would it be coded as a 45378?

    Please, any comments AND back up documentation would be greatly appreciated!!

  2. #2
    Default
    #1 - I would ask the doctor what he means. I have a doctor that always puts on his billing card "polypectomy" which to him means snare. (he is more specific in his op note). If his op notes isn't specific that could be a problem. My first instinct would be to bill 45380.

    #2 - I would bill G0105. V1272 is a code that Medicare specifies as being high risk and should be billed with the high risk screeing code - G0105.

    Hope this helps!
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  3. Default
    Quote Originally Posted by songbird4700 View Post
    We are having a highly spirited debate at my office regarding the documentation of a 45380...
    AND of 45378 vs HCPCS codes.

    I would love to hear any and all comments regarding this.

    Here is the scenario #1

    Patient is seen for a colonoscopy, a polyp is found and removed. The problem lies in the physician's documentation of the removal. He indicated that the polyp was removed via "biopsy forceps". Would you immediately code as a 45380? Or would you question the physician, asking whether or not the forceps used were hot or cold?

    Scenario #2

    Medicare patient is seen for colonoscopy with an indication of V12.72, personal history of polyps. No polyps, masses, or lesions are found. Is this coded as a G0105, high risk screening? Or, because the actual term "screening colonoscopy" is never mentioned, would it be coded as a 45378?

    Please, any comments AND back up documentation would be greatly appreciated!!
    Scenario #1-I would query the MD for type of forceps used, hot or cold, since this does affect the code selection.
    Scenario #2-If the patient had no signs or symptoms I would code G0105 even if it's not stated as a screening. If anemia, change in bowel habits, etc. is mentioned I would code 45378.

Similar Threads

  1. CPC practice exam questions vs. CPC actual exam questions
    By kbearden1985 in forum Medical Coding General Discussion
    Replies: 12
    Last Post: 02-02-2017, 12:43 PM
  2. Documentation on correct documentation placement of procedure notes in the EMR
    By ashephard in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-25-2014, 04:36 PM
  3. Documentation questions
    By tfischer in forum E/M
    Replies: 2
    Last Post: 08-19-2010, 12:00 PM
  4. Questions re: documentation of Consult-E/M
    By AmyLitterell in forum Auditing General Discussion
    Replies: 1
    Last Post: 07-02-2010, 04:55 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.