Health Information Management

Report biopsy code only once when physician performs multiple biopsies

APCs Insider, February 29, 2008

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Regardless of how many biopsies a physician takes from a particular patient, report the appropriate biopsy code only once. Coders may need to append modifier -59 on the biopsy code for codes 45380 and 45385, but list both of these codes only once.

Coders may need to append modifier -59 on the biopsy code because some payers feel a biopsy is incidental to removal. Therefor, only report it when the service would otherwise be denied. Physicians should document the type of tissue removed when dealing with different areas of the colon. Quality documentation will include the type of tissue removed; it just doesn't tie into the coding.

(The above tip was excerpted from the February issue of Briefings on APCs).



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