American Health Information Management Association (AHIMA) Certification Practice Exam

If a physician does not specify the removal method of a lesion during endoscopy, what is the proper course of action?

1. Assign the removal by snare technique code.

2. Assign the removal by hot biopsy forceps code.

3. Assign the ablation code.

4. Query the physician as to the method used.

The correct answer is: Query the physician as to the method used.

The proper course of action when a physician does not specify the removal method of a lesion during endoscopy is to query the physician as to the method used. This step is essential because accurate coding depends on specific details regarding the procedure performed. The method of removal can significantly influence the coding process, implications for reimbursement, and the overall clarity of the medical record. By reaching out to the physician for clarification, health information professionals ensure adherence to coding guidelines and the provision of precise information regarding the procedure. This practice also helps protect the integrity of the patient record and enhances communication between coders and providers, ultimately leading to more accurate coding and billing. In contrast, assigning a code based solely on a presumed technique could lead to inaccuracies in documentation and reimbursement issues. Each removal technique—whether it’s by snare, hot biopsy forceps, or ablation—has specific coding implications. Therefore, when the removal method is unspecified, clarification through a direct query is the most reliable approach to ensuring precise coding.