Colonoscopy and Pouchoscopy

jojogi

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Atlanta
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I would code this 44394, 44385. This is a first for me so I am not 100% sure. Any suggestions? Thanks in advance :confused:

_____________________________________________________



PROCEDURE PERFORMED: Colonoscopy and pouchoscopy.


INDICATION: Average risk colorectal cancer screening.

INSTRUMENT:


MEDICATIONS: Versed 3 mg IV, Fentanyl 75 mcg IV.


COMPLICATIONS: There were no obvious complications.


TECHNIQUE: After informed written consent was obtained and after procedure
time out had been performed the patient was placed on her back and moderate
sedation was administered. The colonoscope was then advanced into her
ostomy in the left lower quadrant with the aide of direct visualization.
Colonoscope was then advanced the cecum and then carefully withdrawn with
the mucosa being carefully examined. The scope was withdrawn through the
end of her ostomy and then the patient was placed in the left lateral
decubitus position. Her rectal pouch was then examined under the aide of
direct visualization.


FINDINGS:
1. Cecal polyp measuring 6 mm status-post hot snare polypectomy.
2. Normal colonic mucosa except for scattered diverticuli on both
residual left and right colon.
3. Rectal pouch measuring 15 cm had mild erythema and slightly nodular
appearance in the area status-post cold biopsy x 2.


IMPRESSION:


RECOMMENDATIONS:
1. Followup pathology.
2. Repeat in 5 years.
 
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227
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Nashville
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I can agree with 44394. I'm never sure how to code for scoping the rectal pouch/rectal stump. Have never found a good answer. The only thing I can figure is 44331 which is flex sig with biopsy. I don't see that it's edits out in CCI. I don't think you could code 45385 for the whole thing but have wondered that as well.

Any thoughts anyone?
 
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Polypectomy by Multibite forceps CPT?????

Urgent help required!!!! CPT for Polypectomy by Multibite forceps?????
 

Torilinne

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Denver CO
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Just one thought for use of 45331.....that includes exam of entire rectum and entire sigmoid colon. It doesn't sound as if the sigmoid was explored so a modifier 52 or 53 might be in order.

Just my thoughts!

V Davis CPC CGIC
 
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227
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Nashville
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44385 is incorrect! The code states small intestinal pouch. The rectal stump is surgically created, but only by dividing the colon above it which leaves the remaining rectum intact. 45330 would be more correct if it doesn't edit out.
 
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