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Can I Bill For The Polyp Removal?

ieshiarenee

Networker
Messages
26
Location
Buckeye, Arizona
Best answers
0
Hello everyone,
The physician did a colonoscopy with polypectomy. Can you please take a moment to read the op report, and let me know if I'm able to bill the polypectomy? I know the polyp is listed in the procedures, and the findings, but it's not dictated in the body of the report. Am I able to bill the polyp removal? Does the polyp removal have to be dictated in the body of the report, or am I able to code from the findings? Your help is appreciated!


PROCEDURES:
1. Colonoscopy.
2. Snare polypectomy.

INDICATION:
1. Colon cancer screening.
2. Family history of colon cancer.

FINDINGS:
A small polyp in the sigmoid colon, completely removed.

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Minimal.

ANESTHESIA:
Intravenous sedation by Dr. Rodriguez.

SPECIMEN:
Sigmoid colon polyp.

PROCEDURE IN DETAIL:
Informed consent was obtained. The patient was taken to the endoscopy suite and placed on the stretcher in the left lateral decubitus position. Intravenous access had been established. The patient was placed on blood pressure,
cardiac and pulse oximeter monitors. The patient was administered intravenous sedation and once adequate sedation was achieved, a digital rectal exam was performed. The anal canal was lubricated. There were no obstructing rectal masses. The Olympus video colonoscope was placed into the rectum and rapidly advanced to the cecum, which was identified by the landmark of the
ileocecal valve. This scope was then gradually withdrawn, moving the scope in circumferential fashion visualizing all the mucosa. The prep was excellent.
The scope was retroflexed in the rectum and there was no significant internal hemorrhoidal disease. The scope was straightened and completely withdrawn. The patient was taken to the recovery room and tolerated the procedure well and there were no complications.

PLAN:
We will follow up on the results of the biopsy in 1 week. Interval for further colonoscopy will be determined by this.
 
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