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Gastroenterology Coding Alert

Reader Question:

Know How to Correctly Report Pouchoscopy With Additional Procedures

Published on Mon Mar 12, 2012

Question: Our gastroenterologist recently performed a pouchoscopy. The operative report read like this:The patient was turned around and the scope was changed to an Olympus P CF-180 pediatric video colonoscope. There was an anal stricture but I was able to get the scope beyond this. There was inflamed tissue at 40 cm. I bypassed this. There was a stricture at 100 cm and I was unable to bypass it with the scope. I dilated that with a 20 mm balloon. Then I was able to bypass the stricture and the ileum proximal to it appeared normal. The colonoscope was slowly withdrawn and the ileum and pouch were decompressed. The anus was dilated with a 50 French Maloney dilator. The procedure was then terminated. He tolerated it well. There were no immediate complications.Should I use a colonoscopy CPT® code to describe the procedure that was performed?Georgia SubscriberAnswer: Colonoscopy is a diagnostic [...]
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