Wiki Colonoscopy w/ Snare Biopsy - missing path

[Radiant]

When working a procedure where the documentation supports 45385 but the resulting lab sample is lost - is the procedure still coded snare biopsy?

How does this effect dx?

 

[such78]

code what the surgeon performed. if didn't indicate the finding, code the reason why the patient came in for.

 

[shlyalford]

Yes the procedure would still be coded as so if the doctor indicated within his notes that he use snare technique to left a polyp. The technique of how the procedure was done doesn't necessarily determine the DX, impressions or findings of that procedure. So with the sample being lost the DX would then in return be the indications of WHY that PT had the procedure done.