mhcpc
Guru
Help, Please? I have the following:
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient
was placed in the supine position in the radiology suite. After adequate
sedation had been achieved, the endoscope was inserted over the tongue and
through the posterior pharynx under direct visualization into the
esophagus. In the mid esophagus, a very tight stricture was found, which
would not allow passage of the scope. Under fluoroscopy, a Savory
guidewire was placed through this and into the stomach. The stricture was
then dilated with passage of a 27 French gauge Savory dilator without
resistance. A 36 French gauge dilator passed with moderate resistance. A
42 French gauge Savory dilator would not pass without excessive resistance.
The scope was reinserted. Only a very small amount of mucosal trauma was
identified. A CRE balloon was then inserted and under visualization, it
was placed into the stricture. This was inflated to 12 mm and held for one
minute. The balloon was then deflated. The scope was able to be slightly
advanced about 2 cm but then stopped. The balloon was reinflated to 12 mm
and held for an additional minute. The scope would not pass through the
stricture at this point. The balloon was then reinflated to 13.5 mm and
held for one minute and finally to 15 mm and held for one minute.
Unfortunately, when the balloon was deflated and withdrawn, the scope still
would not pass through the stricture. A decision was, therefore, made to
terminate the endoscopy.
I have never had a physician use 2 different types of dilation. I know they aren't bundled, but can we charge both? I know there will have to be a 53 modifier used since he had to terminate the procedure, but how would you code?
Thanks,
Michele Hayes, CPC, CGIC
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient
was placed in the supine position in the radiology suite. After adequate
sedation had been achieved, the endoscope was inserted over the tongue and
through the posterior pharynx under direct visualization into the
esophagus. In the mid esophagus, a very tight stricture was found, which
would not allow passage of the scope. Under fluoroscopy, a Savory
guidewire was placed through this and into the stomach. The stricture was
then dilated with passage of a 27 French gauge Savory dilator without
resistance. A 36 French gauge dilator passed with moderate resistance. A
42 French gauge Savory dilator would not pass without excessive resistance.
The scope was reinserted. Only a very small amount of mucosal trauma was
identified. A CRE balloon was then inserted and under visualization, it
was placed into the stricture. This was inflated to 12 mm and held for one
minute. The balloon was then deflated. The scope was able to be slightly
advanced about 2 cm but then stopped. The balloon was reinflated to 12 mm
and held for an additional minute. The scope would not pass through the
stricture at this point. The balloon was then reinflated to 13.5 mm and
held for one minute and finally to 15 mm and held for one minute.
Unfortunately, when the balloon was deflated and withdrawn, the scope still
would not pass through the stricture. A decision was, therefore, made to
terminate the endoscopy.
I have never had a physician use 2 different types of dilation. I know they aren't bundled, but can we charge both? I know there will have to be a 53 modifier used since he had to terminate the procedure, but how would you code?
Thanks,
Michele Hayes, CPC, CGIC
