Wiki diagnosis help-If the physician removes

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tsmith

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If the physician removes what he thinks is a polyp, but the path report comes back as colonic mucosa with no diagnostic features, can this still be coded as a benign polyp? If not, can you medically support the polypectomy CPT code or would you just code the 45378. There were no other findings on the colonoscopy.

Similar scenario with an EGD. Report states the physician saw esophagitis, but this is not supported by the path report. Can you still code esophagitis since he visualized the inflammation?
 
I would probably go back to signs/symptoms or the original reason for doing the colo. Not sure I would use 569.89 as it reads, "Other specified disorders of intestine" and the path doesn't support this. You can still report a biopsy code (95380) with signs and symptoms if there is nothing that was found.

V. Davis, CPC, CGIC
 
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