I'm a little confused about this procedure and how to code it.
Procedure: The colonoscope was passed through the anus under direct visualization to approximately 20 cm from the anal verge. Unable to advance scope proximal to 20 cm the scope was withdrawn and the mucosa was carefully examined. Semisolid stool was present. The patient's toleration of the procedure was good. The views were fair after careful flushing. Scope was then passed through the colostomy to cecum without difficulty. Prep was good.
Findings: Scope initially advanced through rectum. There was a frond-like/villous tumor was visualized at approximately 15 cm proximal to anal verge which occupied 75 to 99% of the circumference of the colon. It was causing intrinsic narrowing. Multiple biopsies were taken. Unable to advance proximal to 20 cm, the specimens were collected for pathology. The distal was then advanced through stoma to cecum. Rare diverticula were visualized but no polyps or mucosal abnormalities were visualized as scopr was slowly removed.
I know they went through the stoma, as well as the anus.
I know there were biopsies taken, as well as injections of ink for the tattoos given.
These are the codes I am looking at:
44389- Colonscopy through stoma; with Biopsy, single or multiple
45381- Colonscopy, flexible, proximal to splenic flexure; with directed submocosal injection(s), any substance
45331- Sigmoidoscopy; with biopsy, single or multiple
45335 Sigmoidoscopy; with directed submucosal injection(s), any substance
Any and all help is appreciated.
Thanks in advance
Procedure: The colonoscope was passed through the anus under direct visualization to approximately 20 cm from the anal verge. Unable to advance scope proximal to 20 cm the scope was withdrawn and the mucosa was carefully examined. Semisolid stool was present. The patient's toleration of the procedure was good. The views were fair after careful flushing. Scope was then passed through the colostomy to cecum without difficulty. Prep was good.
Findings: Scope initially advanced through rectum. There was a frond-like/villous tumor was visualized at approximately 15 cm proximal to anal verge which occupied 75 to 99% of the circumference of the colon. It was causing intrinsic narrowing. Multiple biopsies were taken. Unable to advance proximal to 20 cm, the specimens were collected for pathology. The distal was then advanced through stoma to cecum. Rare diverticula were visualized but no polyps or mucosal abnormalities were visualized as scopr was slowly removed.
I know they went through the stoma, as well as the anus.
I know there were biopsies taken, as well as injections of ink for the tattoos given.
These are the codes I am looking at:
44389- Colonscopy through stoma; with Biopsy, single or multiple
45381- Colonscopy, flexible, proximal to splenic flexure; with directed submocosal injection(s), any substance
45331- Sigmoidoscopy; with biopsy, single or multiple
45335 Sigmoidoscopy; with directed submucosal injection(s), any substance
Any and all help is appreciated.
Thanks in advance