Don't Report Multiple Codes for Multiple Polyps
Question: When the physician removes several colon polyps, he usually uses the same technique for all of them. Recently, though, we had a chart in which the physician treated polyps with different removal methods during the same operative session. Can we report multiple codes in these situations?
Arkansas Subscriber
Answer: You should report all polyp-removal codes once per operative session, regardless of the number of polyps the physician removes. Therefore, when he performs a colonoscopy to remove more than one polyp during the same patient encounter using the same method, you cannot report multiple codes.
For instance, if the doctor removes and cauterizes three polyps during a colonoscopy, you should report a single unit of 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) to describe the encounter.
In contrast, if the physician ablated one polyp with an argon plasma coagulator, then removed the other two by snare technique, you would do the following:
Remember: Be sure your documentation supports the two removal methods and explains why both were necessary.
Question: Does a patient need to sign a release to find out how long he was under anesthesia?
Ohio Subscriber
Answer: The patient has the right to access all of his healthcare information - it's his, and you are the caretaker. He doesn't need to sign a release, but you might want to have a record of him signing the information out, as well as identification to confirm that he is indeed the patient.Alternatively, the patient could send the hospital a written request to access the information. No one there needs to interpret it for him. You should just provide him with the records - anesthesia or surgery reports, or whatever else he'd like to see - and let it be his to read as he pleases.
Question: We received an x-ray order without a diagnosis or symptoms listed. Should we return it to the x-ray department, or call the doctor for the necessary information?
Rhode Island Subscriber
Answer: Your course of action may depend on your hospital's accepted practice. At some facilities, you may be just fine contacting the physician yourself (and that may be the quickest solution). Others prefer that the query for updated written orders come from the staff at the point of service - in this case, the radiology department - because they should have all the appropriate documentation before they perform the procedure.
Remember: The order from radiology should include the type of procedure, the diagnosis, the patient's name, and the ordering physician's signature.
The diagnosis is especially important when performing certain radiology examinations. For example, if the physician orders a computed tomography scan of the abdomen/pelvis because he wants to rule out a patient's kidney stone, it is imperative that the radiologist perform the examination without contrast. But if the diagnosis is appendicitis, the radiologist should perform the procedure with rectal contrast (depending on radiologist protocol). Another way to highlight different pathologies in the examination is with intravenous contrast.
Bottom line: Whether the procedure was performed with or without contrast determines which HCPCS code you'll report. At times, the radiologist will determine which examination is appropriate based on the diagnosis - so the radiology department needs to contact the ordering physician prior to performing the examination for accurate documentation.
- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
