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please help, new to gastro?

Annette Posted Wed 26th of May, 2010 15:57:34 PM

I have two op reports, dr wants to bill 45383, 45381 & 45385 for the first one & 45383, 45382 & 45381 for the second one. & since Im totally & completely new with gastroenterology I have no idea if that is correct?

1. The olympus scope was passed in the transverse colon. Excellent prep. The lesion itself was at approximately 9cm in the rectosigmoid or upper one third of the rectum really. With the rotatable snare, the base was encircled, and the polyp removed, and then another small piece that was still on the wall was removed, thereby, removing the entire lesion. This was retrieved, put in a pathology battle. The area was then re-examined. Because there was a diagnosis of dysplasia, it was elected to use the APC with 360 head post polypectomy setting which was done, and the entire area was APC'd under narrow band light. This was removed, the Argon removed, andthen a tattoo with a spot material was used and photgraphs taken.

2. DX: significiant lower gastrointestinal bleed status post polypectomy of the ascending colon 1 day ago. bleeding site at polypectomy area of proximal ascending colon.
Digital rectal examination was performed, after which the PCF160 video colonoscope was inserted into the rectum and advanced to the cecum. there was old blood throughout the whole colon. In the area of the proximal ascending colon, the site of the previous polypectomy was visualized with fresh clot hanging out, with drops of blood coming out under the clot. Those findings confirmed. The epinephrine injection submucosally was performed; first circumferentially at the polypectomy site. This arrestedthe bleeding. Now the clot was removed with cold biopsy forceps and the base of the polypectomy site was treated with Argon plasma coagulator. nice eschar was achieved and bleeding was completely controlled. upon withdrawal of the scope old blood was suctioned out as much as possible. There were other bleeding sites noted.

thank you so much!!

SuperCoder Answered Thu 27th of May, 2010 06:21:01 AM

You are correct that the first report can be billed with CPT 45381, 45383 and 45385-59. For the second report code 45382 because the patient came only for the control of bleeding with injection and coagulation with APC device so you can code only 45382. So report this code without a 78 modifier (0 global period)along with a post-op bleeding Dx.

SuperCoder Answered Thu 27th of May, 2010 07:56:41 AM

For the 2nd OP notes, use 998.11 as the post-op bleeding and link it with 45382. Do not code 578.9 (lower GI bleeding) as the Dx code, as the colon bleeding is the result of previous day's surgery only.

Annette Posted Thu 27th of May, 2010 12:46:38 PM

yes I did have come up with that dx 998.11. thank you both!

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