Carol Posted Tue 18th of June, 2013 15:46:45 PM
How would you bill a colonoscopy with snare polypectomy and prophylatic clipping in a patient currently off of blood thinners but in view of the possible need for resuming anti-coagulation therapy, clip was deployed overthe polypectomy site. Confused as to whether clip can be billed in view of the fact that the patient was OFF of blood thinners previously and at the time of the procedure.
SuperCoder Answered Wed 19th of June, 2013 11:18:36 AM
If the control of bleeding occurs during the same operative session, then the service is included in the primary procedure (45385). If the control of bleeding occurs on the same day but during a separate operative session, then you would attach modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 45382 (Colonoscopy with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) to indicate that it was done in a different session from the initial endoscopy. If the bleeding is first recognized and treated outside the post-operative period on a different calendar day, then it would be appropriate to file a claim for control of bleeding using 45382.
Clipping cannot be billed in your case.