narsenault
New
How would you code this colonoscopy? This is the redacted operative note below. I am welcome to all information or comments you have. Thank you, Nicole Arsenault
Indications: History and colon polyps.
Procedure name: Colonoscopy and biopsy
Details of procedure: The digital rectal exam was normal. Colonoscope was introduced into rectum and advanced to cecum. The bowel prep was satisfactory. The cecal structures were clearly identified and a careful examination of cecum colorectum was performed. Patient had a single small hyperplastic appearing polyp in the left transverse colon close to the splenic flexure. This was biopsied and cauterized. Was no evidence of diverticulosis and retroflexion in the rectum was normal.
Post procedure diagnosis: Benign appearing colon polyp.
Suggested follow up: Pending pathology.
Indications: History and colon polyps.
Procedure name: Colonoscopy and biopsy
Details of procedure: The digital rectal exam was normal. Colonoscope was introduced into rectum and advanced to cecum. The bowel prep was satisfactory. The cecal structures were clearly identified and a careful examination of cecum colorectum was performed. Patient had a single small hyperplastic appearing polyp in the left transverse colon close to the splenic flexure. This was biopsied and cauterized. Was no evidence of diverticulosis and retroflexion in the rectum was normal.
Post procedure diagnosis: Benign appearing colon polyp.
Suggested follow up: Pending pathology.
