Wiki cauterization of polyps

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Networker3412

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does anyone know if a physician states in his op note that he uses cauterization that this is the same thing as saying that he used hot biopsy forceps? We have a physician that states when he uses this term "cauterization" that means the same thing as hot biopsy forceps. or does he have to say "hot biopsy forcep" in his op note. Can our facility just have in writing from the physician this statement that cauterization means hot biopsy forcep for this physician?
 
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Hot Biopsy

It is always better if a physician specifies which technique he uses. It is confusing for coders and payors when reports are reviewed. Be careful when the physician states that he performed a snare polypectomy with quarterization. The 45385 code would be applicable here. Hope this is of help to you.
 
our physician states that he does not have to put hot biopsy or snare in his op report because he always states cauterization and he states that always means hot biopsy CPT code 45384. we tried to show him the guidelines but he stands behind his statement that everytime he says cauterization that means hot biopsy forceps. Does anyone know if the physician just make a general statement to the hospital that when he states cauterization this means hot biopsy forceps if we can use that or he specifically has to state that in his op note on every patient??? i thought he had to state that in his op note otherwise how are we to know.....
 
Maybe the doctor would be willing to add the word bipolar to his op report. 45384 indicates polyp removal by "hot biopsy forceps OR bipolar cautery".
 
If a document is prepared stating this is a standard accepted practice policy, then you can code the 45384. It must be kept on file with all other practice policies

This would also have to be made available to any auditor. There can be no exceptions. No flip-flopping. And it must be a "practice policy" not physician specific
 
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