Wiki Help with Coding, please

[ENDOCODER]

My flow sheet states colon w/ excisional bx with cold snare. report states 2 polyps found in cecum. The polyps were removed with cold snare and cold bx forceps and placed in jar 1. Asked Dr., he said one polyp was removed with snare and one was removed cold biopsy. He wasn't changing report. Is this acceptable? Need some advise on this. I think it should say one polyp removed via cold snare and one polyp removed cold biopsy forceps. Two different polyps, two diff techniques in same area.

 

[kathleenw84]

Yes, it is sufficient

Your physician is answering in logical order of sequence, without alot of extra verbage. I believe it is enough and fairly easy to follow what he/she did, even for an auditor.

 

[ENDOCODER]

So even though he doesn't say in the report that one polyp was removed by snare technique and the other polyp removed by cold bx forceps we can bill both procedures? To me it looks like he used both snare and cold bx on both polyps. Appreciate your response.