# CPT Code 45380



## BKDaniels (May 16, 2016)

Hi  
I have a coder receiving an edit in the grouper that we are exceeding our units of 45380.  She coded the below op report with 45380, 45380-59 to indicate the separate biopsy sites.  Can anyone tell me why this isn't justified?

 Examination of the perianal region was normal.  Rectal exam unremarkable.  The
 Olympus PF-190L videocolonoscope was inserted into the rectum and advanced to
 the cecum as well as distal TI with good visualization throughout.  The patient
 having a 0.5 cm polyp cold biopsy removed in the transverse colon with localized
 superficial erythema in the cecum, biopsies of which were taken, path is
 pending.  Patient had a 0.5 cm polyp, cold biopsy removed the ascending colon. 
 There was mild left-sided diverticular disease.  The remaining colon, rectum to
 cecum including ileocecal valve and distal TI was otherwise unremarkable.  Bowel
 was decompressed.  The scope was withdrawn.  The patient tolerated the procedure
 well.

 IMPRESSION:
 1.  Status post 0.5 cm polyp cold biopsy removed in the transverse colon.  Path
 is pending.
 2.  Status post biopsies of cecal erythema.  Biopsies taken, path is pending.
 3.  Status post 0.5 cm polyp cold biopsy removed in the proximal ascending colon
 with the remaining colon, rectum to cecum otherwise unremarkable.

 PLAN:
 Recommend the patient avoid salicylates, nonsteroidals x1 week.  We will check
 the path report, depending on the findings we would make further
 recommendations.

Thank you!!


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## CodingKing (May 16, 2016)

Code description is single or multiple so it should never be reported more than once per encounter no matter how many biopsies are done.


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