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With the patient in the left lateral decubitus position, digital rectal examination was performed and unremarkable. Using a Fujinon video colonoscope, it was advanced through the patient's anus and into the rectum without difficulty. Under direct vision, the instrument was advanced retrograde to only approximately the level of the mid sigmoid colon. At this point, I encountered significant diverticular disease and could never find the lumen beyond this point. There was also sharp angulation. After trying multiple maneuvers, I decided to terminate the procedure at this point. I felt the risk at this point and with the benefits of potential perforation. Subsequently using biopsy forceps, I obtained random distal sigmoid colon biopsies to rule out the possibility of microscopic colitis. These were all sent to pathology for further evaluation. The instrument was withdrawn in the rectum and retroflex examination of the internal anal canal. Small non-bleeding internal hemorrhoids were noted and two polyps were noted within the rectum. There was a larger 6 to 8-mm pedunculated rectal polyp too best identified on retroflex view. Each of these polyps was removed. The larger polyp was removed using electrocautery polypectomy snare technique, retrieved, and sent to pathology for evaluation. The smaller approximately 4-mm sessile polyp was removed using biopsy forceps and sent to pathology. The instrument was withdrawn.
Any thoughts on this one? Would I code 45378 with 74 and then 45338 and 45331-59? Any help is greatly appreciated!!! Thank You
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I would think you would want to code the intended procedure which was the colonoscopy (especially if this was a screening or the patient is being brought back in for a barium enema). If you code the colonoscopy I don't think you would code the lesser procedure (sigmoidoscopy) since it is part of the bigger procedure. So, I'm thinking 45385-74 & 45380-59-74. I could be way off base, but that's my logic. I hope this didn't make things worse...:confused: