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Hi,
I have a question that can we code family history of colon polyps as per following report.
Indications for procedure: This is a very pleasant 68-year-old gentleman with a family history of gastrointestinal emergency. The patient has never had a prior colonoscopy. Risks and benefits of colonoscopy were discussed with the patient and verbal and written consent was obtained.
Detailed Description of Procedure: After verbal and written consent, the patient was brought to the endoscopy suite. A timeout was performed staff in room confirming the patient, procedure to be performed. The procedure was began with a rectal exam demonstrating normal tone, movement, and moderate external hemorrhoids. Colonoscope was then inserted and patient was advanced to the cecum without difficulty. The ileocecal valve and appendiceal orifice were identified. The prep was noted to be adequate to identify polyps and some residual retained liquid stool inside the portions of the colon. The patient had 3 separate polyps in the ascending colon which were excised with a cold snare and retrieved. The patient had evidence of moderate sigmoid diverticulosis without evidence of inflammation or stricturing. The patient had evidence of a rectosigmoid polyp at approximately 20 cm which was also excised with adenocarcinoma and retrieved. Retroflexion the rectum was performed demonstrating no distal rectal lesions. The endoscope was straightened and removed. The patient tolerated procedure well and was transported to the recovery stable addition. There were no immediate complications. Recommend repeat colonoscopy in 2 to 3 years given his history of multiple polyps as well as family history.
I have a question that can we code family history of colon polyps as per following report.
Indications for procedure: This is a very pleasant 68-year-old gentleman with a family history of gastrointestinal emergency. The patient has never had a prior colonoscopy. Risks and benefits of colonoscopy were discussed with the patient and verbal and written consent was obtained.
Detailed Description of Procedure: After verbal and written consent, the patient was brought to the endoscopy suite. A timeout was performed staff in room confirming the patient, procedure to be performed. The procedure was began with a rectal exam demonstrating normal tone, movement, and moderate external hemorrhoids. Colonoscope was then inserted and patient was advanced to the cecum without difficulty. The ileocecal valve and appendiceal orifice were identified. The prep was noted to be adequate to identify polyps and some residual retained liquid stool inside the portions of the colon. The patient had 3 separate polyps in the ascending colon which were excised with a cold snare and retrieved. The patient had evidence of moderate sigmoid diverticulosis without evidence of inflammation or stricturing. The patient had evidence of a rectosigmoid polyp at approximately 20 cm which was also excised with adenocarcinoma and retrieved. Retroflexion the rectum was performed demonstrating no distal rectal lesions. The endoscope was straightened and removed. The patient tolerated procedure well and was transported to the recovery stable addition. There were no immediate complications. Recommend repeat colonoscopy in 2 to 3 years given his history of multiple polyps as well as family history.