Wiki Coding for polyp not retrieved during colonoscopy

[Hite]

Can someone give me information on how to code for a polyp removal by snare during colonoscopy that was not retrieved during procedure. Do you code for the snare even through no speciman was retrieved and sent to pathology with benign polyp dx code or do you just code for the screening colonoscopy with v76.51. I have searched for documentation to support correct coding and have been unsuccessful. I would appreciate any help.

 

[kgoldman CPC COC]

If the polyp was not snared and retrieved then it is just a colonoscopy. Don't forget to code the polyp that was visualized.

Kim Goldman CPC, CPC-H

 

[chewri]

can you please clarify this for me. If a Dr. attempts a snare but the polyp is not retrieved you can only bill for a straight colonoscopy but you can bill a 211.3 cause it was seen? I was taught you can't code a 211.3 if you didn't have a path to say so but you can still bill for the snare as it was still done, just not able to get specimen.
Appreciate your clarification.

 

[Hite]

The Provider did snare the polyp and remove it but it got lost when he was trying to bring it out. No specimen was sent to pathology.

 

[pscar]

polyp not retrived

I am have the exact scenerio. Exception dr did biopsy in the ascending and transverse colon for evaluation of microscopic colitis. Snare was performed in the descending but documented as unretrieved. How to code this?

 

[Jill Barron]

You would still code for 45385 due to the fact that the polyp was snared and removed, even though it was not retrieved.

 

[Hite]

What dx would you use?

 

[Janelle926]

Depending on the insurance company you may bill differently. but generally (medicare 45385-pt 211.3, v76.51) (BCBS 45385-33 v76.51, 211.3) (Other commercial 45385-33 211.3, v76.51) You would still bill for the removal because the Dr DID do it... the specimen just wasn't obtained for pathology.