Gastroenterology Coding Alert
Avoid Mistaking Specimen Collection for Biopsy
Question: During a patient’s routine screening colonoscopy, our gastroenterologist observed approximately a dozen white thin parasites. He performed fluid aspiration through the scope suction channel and sent over the samples to the lab. How should I cod this procedure? Is code 45380 appropriate?
Nevada Subscriber
Answer: You should use 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). In this procedure, the provider examines the inner part of the colon and rectum using a colonoscope, a flexible tube with a camera at its one end. He then may also perform a brushing or washing of the colon to collect specimens. He may also perform a colon decompression during this procedure. You should not report the collection of specimens separately, but the procedure itself is separate from any other procedure that might be performed at the same time.
Code 45380 (Colonoscopy, flexible; with biopsy, single or multiple) is not the appropriate code based on the information that you provided because the physician did not perform an actual biopsy.
Gastroenterology Coding Alert
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