tci Part B Insider - 2012 Issue 6

Reader Question: Modifier 78 Signals 'Unplanned' Return

Question: Our surgeon performed a colonoscopy with polyp removal 45385, and discharged the patient. The patient returned later the same day complaining of bloody stool. The surgeon then did a second colonoscopy to control bleeding. Should we separately code the second colonoscopy?Answer: Because the surgeon performed the bleed control in a separate procedural session, you can bill for it in addition to the primary procedure.Do this: Report the initial colonoscopy as 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Then report the second procedure with the bleeding...

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