Wiki Colonoscopies- Technique Billing

[KBean2018]

Hello, I need some clarification. If a surgeon performs a colonoscopy, ie. polypectomy (cautery snare and hot biopsy forcep). Don't you bill for both? I always have but wanted to make sure. I will place the note below.
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The patient was brought back to the endoscopy suite and was properly monitored and positioned. IV sedation was administered. The anal verge was inspected. A digital rectal exam was performed. The Olympus video colonoscope was then inserted and passed under direct vision to the cecum. The degree of difficulty was minimal. The prep was good. The scope was then withdrawn carefully inspecting all areas of the lower GI tract. Retroflexion was performed in the rectum. Endoscopic findings included see above. Therapeutic procedures included polypectomy using the hot biopsy forceps and cautery snare. Polypectomy site hemostatic. The scope was then withdrawn and the patient tolerated the procedure well.

45385, 45384-59?

Thanks in advance!
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[krithika]

we can bill both, if both the procedures are done on different polyps. if both the procedures are done for the same polyp, then only 45385.

From your op note description, it is not documented whether snare and hot bx is done on the same polyp or different polyp. please post the detailed and complete report.