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45385 and 45380
Any help would be appreciated.
Can you bill 45380-59 for randon biopsies of colon to rule out collagenous colitis when billing 45385?
Ex:
The colonoscope was advanced from rectum to cecum. The cecum and ascending had no evidence of polyps. The ascending and hepatic had extrinsic complession; however, luminally there were no defects. Random biopsies were taken in the colon to rule out collagenous colitis. The remainng portion of the transverse had no polyps, AVMs or bleeding. Then he says proximal secending had 1.25cm polyp was snared. The remaining of portion of descending promial sigmoid had not polyps but mid sigmoid colon 1.25 snared. The remaining portion of the sigmoid and rectum had no evidence of polyps.
Question: Can I assume that the biopsies that he says colon he actually means in acending colon and hepatic flexure? So would it be appropriate to bill 45385, 45380-59?
Thank You!
re: 45385 and 45380
Documentation must support medical necessity (no assumptions).
Here is an example: if multiple polyps or lesions are removed with different techniques, you may report each separately. For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59.