dyoungberg
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I submitted the following op note to Medicare:
PROCEDURE: COLONOSCOPY WITH SNARE POLYPECTOMY AND ABLATION
INDICATION: RECTAL BLEEDING, INCONTINENCE
SEDATION: PER ANESTHESIA
DESCRIPTION OF PROCEDURE: After discussion with the patient, the risks and benefits of the procedure, informed consent was obtained. Digital rectal examination did not reveal the presence of mass or fistula. The Olympus colonoscope was introduced through the patient's rectum and advanced to the cecum in the usual technique. Cecum was identified by the presence of the ileocecal valve and the appendiceal orifice. The quality of prep was good. Thorough examination of entire mucosa was performed while endoscope was withdrawn.
Normal cecum, normal ileocecal valve. Ascending colon with semi sessile polyp, 8.0 mm's, removed with snare polypectomy. Transverse colon within normal limits. Descending colon and sigmoid colon with moderate to severe diverticulosis. In sigmoid colon a sessile polyp was seen, biopsies were taken, then polyp was destroyed with ablation, size 8.0 mm's. Rectum within normal limits. On retroflexion moderate internal hemorrhoids were seen. The colonoscope was completely withdrawn from the patient and the procedure terminated. The patient tolerated the procedure well.
COMPLICATIONS: NONE
ENDOSCOPIC IMPRESSION:
1. ASCENDING COLON POLYP, REMOVED WITH SNARE POLYPECTOMY
2. SIGMOID COLON POLYP, DESTROYED WITH ABLATION
3. MODERATE TO SEVERE DIVERTICULOSIS
4. INTERNAL HEMORRHOIDS
I coded this as 45385 - 211.3,455.0,562.10 & 45383/59 - 211.3,455.0,562.10. Medicare denied payment of 45385 stating the codes are bundled together and not separately payable. We appealed and they still denied.
It's my understanding I could code both as polyps were removed from 2 different sections of the colon in 2 different ways.
Was I wrong in my coding?
Debbie
NW FL Surgery Center
PROCEDURE: COLONOSCOPY WITH SNARE POLYPECTOMY AND ABLATION
INDICATION: RECTAL BLEEDING, INCONTINENCE
SEDATION: PER ANESTHESIA
DESCRIPTION OF PROCEDURE: After discussion with the patient, the risks and benefits of the procedure, informed consent was obtained. Digital rectal examination did not reveal the presence of mass or fistula. The Olympus colonoscope was introduced through the patient's rectum and advanced to the cecum in the usual technique. Cecum was identified by the presence of the ileocecal valve and the appendiceal orifice. The quality of prep was good. Thorough examination of entire mucosa was performed while endoscope was withdrawn.
Normal cecum, normal ileocecal valve. Ascending colon with semi sessile polyp, 8.0 mm's, removed with snare polypectomy. Transverse colon within normal limits. Descending colon and sigmoid colon with moderate to severe diverticulosis. In sigmoid colon a sessile polyp was seen, biopsies were taken, then polyp was destroyed with ablation, size 8.0 mm's. Rectum within normal limits. On retroflexion moderate internal hemorrhoids were seen. The colonoscope was completely withdrawn from the patient and the procedure terminated. The patient tolerated the procedure well.
COMPLICATIONS: NONE
ENDOSCOPIC IMPRESSION:
1. ASCENDING COLON POLYP, REMOVED WITH SNARE POLYPECTOMY
2. SIGMOID COLON POLYP, DESTROYED WITH ABLATION
3. MODERATE TO SEVERE DIVERTICULOSIS
4. INTERNAL HEMORRHOIDS
I coded this as 45385 - 211.3,455.0,562.10 & 45383/59 - 211.3,455.0,562.10. Medicare denied payment of 45385 stating the codes are bundled together and not separately payable. We appealed and they still denied.
It's my understanding I could code both as polyps were removed from 2 different sections of the colon in 2 different ways.
Was I wrong in my coding?
Debbie
NW FL Surgery Center