You are a new coder at Northwood Tech Hospital. You begin training with another coder who is an RHIT and has over 15 years of outpatient coding experience.

Scenario:  You are a new coder at Northwood Tech Hospital. You begin training with another coder who is an RHIT and has over 15 years of outpatient coding experience. As she is training you to code colonoscopies, she indicates that whenever the provider performs a polypectomy, it is considered a snare technique. You do not notice any documentation within the procedure note to support “snare” and question the coder. She indicates that the same provider has been completing these procedures for the last ten years, and he indicated a few years back that whenever he does a polypectomy, it is always done with a snare and this is how she has been coding them ever since. She indicates it is easier to code them this way than querying on every case or training the provider on appropriate documentation. Besides, he is a very difficult provider to work with. She states that you can ask the provider yourself for validation.

What is wrong with coding a polypectomy to the snare technique? Provide specific information to support your answer. This could be a coding guideline, differences in codes, etc.

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