We had a pt come in for a screening colonoscopy 45378 dx v76.51, the doc found polyps and had to send them for biopsy so would I also use CPT® code 45380 or 45385 with a dx of 211.3 and would I use a modifier PT or 59. Please help!!! Thank You
First off, if the doctor snared the polyp you would use 45385. If he just biopsied the polyp, you would use 45380. I would wait for the pathology results before I billed it to make sure it is a polyp and whether or not it is benign or malignant. If it is benign, you are right with 211.3. Then, you would use PT if the patient is Medicare to show it started off as a screening and then turned diagnostic.