Code this report as if you work for the hospital. Coding Hint: There are four di
ID: 243710 • Letter: C
Question
Code this report as if you work for the hospital.
Coding Hint: There are four diagnosis codes, one z-code, and two CPT codes with an appropriate modifier associated with this report.
PROCEDURE: Colonoscopy.
INDICATIONS: A history of adenomatous polyp and family history of colon cancer.
ANESTHESIA: Fentanyl 100 mcg IV and Versed 2 mg IV.
INSTRUMENT: Olympus video colonoscope.
PREPARATION: Adequate.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the endoscopy (?) and placed in the left lateral decubitus position. The above IV sedatives were given until adequate anesthesia was achieved. After doing a rectal exam, which was unrevealing, the Olympus video colonoscope was placed in the patients rectum and proceeded slowly and carefully under direct vision to the cecum. The cecum was identified using landmarks. The colonic mucosa appeared normal. Colonoscope was withdrawn. In the descending was a small, polyp which was removed by hot biopsy. Colonoscope was withdrawn. Transverse colonic mucosa appeared normal. There was left-sided diverticulosis noted, mostly in the sigmoid. There was a small sigmoid polyp which was removed by cold biopsy with good hemostasis. On retroflexion, in the rectum there were internal hemorrhoids. The colonoscope was retreflected and withdrawn. The patient tolerated the procedure well. There were no complications.
FINDINGS: Benign polyps, diverticulosis, and hemorrhoids.
RECOMMENDATIONS: Await pathology results. High-fiber diet and stool softeners.
Explanation / Answer
CPT codes are:
* 44388 Colonoscopy through stoma: diagnostic, with or without
collection of specimen(s) by brushing or washing ( modified code is 45378)
* 44389 with biopsy, single or multiple j K-pop( modified code is 45379).
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