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General Surgery Coding Alert

You Be the Coder:

Depend on 78 for Bleeding Control Return

Published on Thu Jan 19, 2012

Question: Our surgeon performed a colonoscopy with polyp removal 45385, and discharged the patient. The patient returned later the same day complaining of bloody stool. The surgeon then did a second colonoscopy to control bleeding. Should we separately code the second colonoscopy?Indiana SubscriberAnswer: Because the surgeon performed the bleed control in a separate procedural session, you can bill for it in addition to the primary procedure.Do this: Report the initial colonoscopy as 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Then report the second procedure with the bleeding control using 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). You must append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related [...]
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