Sherry Posted Thu 25th of January, 2018 14:58:37 PM
The Flex scope was introduced through the anus and advanced to the sigmoid colon.
Findings: The muscosal vascular pattern in the rectum was locally increased, friable anteriorly, typical for radiation proctitis.
-Lavage of the area was performed using 20mL of 4% formalin in sterile water, resulting in vascular blanching with the patient in the prone reverse trendelenberg position.
Normally the bleeding control with formalin is usually stating its injected OR bleeding control through the APC method; can we consider the way they state it above as a bleeding control method as well or do we need to use the base code because it doesn't actually inject the area but lavash it. Any assistance would be greatfully appreciated! Thanks.
SuperCoder Answered Mon 29th of January, 2018 02:24:17 AM
Physician has performed lavage of the area using 20mL of 4% formalin in sterile water. So this does not need to be coded separately.
Please feel free to write if you have any question.
Sherry Posted Tue 30th of January, 2018 05:50:48 AM
So do we bill that as bleeding control then?
SuperCoder Answered Wed 31st of January, 2018 01:39:56 AM
If medical record says something different, other than stated in this question, please let us know. Otherwise please see our answer below.
You cannot bill that as bleeding control because documentation states “Lavage of the area was performed using 20mL of 4% formalin in sterile water” and we do not bill lavage separately.
Hope it helps.
Sherry Posted Wed 31st of January, 2018 01:50:14 AM
No it is worded exactly as is on this forum, so because of the lavage, we can't bill the bleeding control then? I should go and bill 45330 only then correct? Sorry I just want to make sure I understand it correctly so that I can bill it and explain why we can't bill bleeding control regardless of the "Formalin," used. Thanks!
SuperCoder Answered Thu 01st of February, 2018 05:52:51 AM
Lavage >is part of the main procedure. So you cannot bill it separately. Just bill code 45330.
Sherry Posted Fri 02nd of February, 2018 09:16:28 AM
Thank you so much for your assistance! :)
SuperCoder Answered Mon 05th of February, 2018 01:52:07 AM
We are always happy to help our invaluable customers.