Cats3
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- Messages
- 29
- Location
- Auburn, MI
Could anyone tell me how I would code the following? I believe it's 47999, but does this one code cover everything? If so what code do I compare it to? Any help would be appreciated.
The patient underwent general anesthesia, which was administered by an anesthesia professional. The patient's blood pressure, heart rate, level of consciousness, oxygen saturation, respirations, ECG and ETCO2 were monitored throughout the procedure. The scope was introduced into the mouth through a bite block and advanced to the second part of the duodenum. Insufflated with carbon dioxide. Clinical intention completely achieved. The patient's estimated blood loss was minimal. The procedure was not difficult. The patient tolerated the procedure well. There were no apparent adverse events.
Findings
The scout film showed clips in the right upper quadrant consistent with prior cholecystectomy. AXIOS stent in mid abdomen
C0M4 Barrett's esophagus observed with 3 tongues and no associated lesion. The diaphragmatic impression was 40 cm from the incisors, Z-line was 40 cm from the incisors and the top of gastric folds was 40 cm from the incisors. The most proximal island was 36 cm from the incisors. The total length of Barrett's esophagus was 4 cm
Previous Roux-en-Y gastric bypass in the stomach. Healthy appearing approximately 2 cm in size.
The jejunum appeared normal.
One lumen opposing metal stent was visualized in the blind limb with the excluded stomach visible through it. The stent was intubated with a therapeutic gastroscope with mild resistance. The excluded stomach was normal in appearance. Erythematous with bilious contents. The scope was advanced second-portion of the duodenum which was normal in appearance. During passage he noted a mild narrowing of the pylorus. To ease passage of the ERCP scope through the stent and the pylorus the decision was made to dilate both.
Performed balloon dilation using fluoroscopic guidance in the jejunogastrostomy. The dilator was expanded from 15 mm starting size to 16.5 mm ending size. Dilation caused improved passage of the scope.
Performed balloon dilation using fluoroscopic guidance in the pylorus. The dilator was expanded from 15 mm starting size to 18 mm ending size. Dilation caused improved passage of the scope. Therapeutic endoscope was withdrawn and a through-the-scope clip used to secure the proximal flange to the jejunal mucosa.
The therapeutic endoscope was withdrawn and the duodena scope advanced through the Axios stent to the second portion of the duodenum.
The major papilla was visualized. The major papilla was native. The major papilla had a bulging appearance.
The common bile duct was deeply cannulated after 1 attempt using a traction sphincterotome with 270 cm x 0.025" straight guidewire. No bleeding was observed
An initial contrast injection was performed successfully in the common bile duct. The injection extended throughout the biliary tree except the cystic duct. Ductal flow was adequate. The study's image quality was acceptable.
Generalized dilation was observed in the common bile duct with a maximal diameter of 20 mm with multiple filling defects consistent with choledocholithiasis.
Complete large biliary sphincterotomy was performed using a sphincterotome. No bleeding was noted at the procedure site.
Multiple sweeps were performed in the hepatic duct using a balloon, which was dilated from 12 mm to 18 mm with an ending size of 18 mm. Sludge, stones and debris were removed, achieving complete clearance.
Contrast injection with occlusion was performed successfully in the hepatic duct. The injection extended throughout the entire biliary tree. Ductal flow was adequate. The study's image quality was acceptable.
No stone or stricture was observed in the common bile duct.
The ERCP scope was withdrawn and the therapeutic endoscope reintroduced. The stent was in position.
The patient underwent general anesthesia, which was administered by an anesthesia professional. The patient's blood pressure, heart rate, level of consciousness, oxygen saturation, respirations, ECG and ETCO2 were monitored throughout the procedure. The scope was introduced into the mouth through a bite block and advanced to the second part of the duodenum. Insufflated with carbon dioxide. Clinical intention completely achieved. The patient's estimated blood loss was minimal. The procedure was not difficult. The patient tolerated the procedure well. There were no apparent adverse events.
Findings
The scout film showed clips in the right upper quadrant consistent with prior cholecystectomy. AXIOS stent in mid abdomen
C0M4 Barrett's esophagus observed with 3 tongues and no associated lesion. The diaphragmatic impression was 40 cm from the incisors, Z-line was 40 cm from the incisors and the top of gastric folds was 40 cm from the incisors. The most proximal island was 36 cm from the incisors. The total length of Barrett's esophagus was 4 cm
Previous Roux-en-Y gastric bypass in the stomach. Healthy appearing approximately 2 cm in size.
The jejunum appeared normal.
One lumen opposing metal stent was visualized in the blind limb with the excluded stomach visible through it. The stent was intubated with a therapeutic gastroscope with mild resistance. The excluded stomach was normal in appearance. Erythematous with bilious contents. The scope was advanced second-portion of the duodenum which was normal in appearance. During passage he noted a mild narrowing of the pylorus. To ease passage of the ERCP scope through the stent and the pylorus the decision was made to dilate both.
Performed balloon dilation using fluoroscopic guidance in the jejunogastrostomy. The dilator was expanded from 15 mm starting size to 16.5 mm ending size. Dilation caused improved passage of the scope.
Performed balloon dilation using fluoroscopic guidance in the pylorus. The dilator was expanded from 15 mm starting size to 18 mm ending size. Dilation caused improved passage of the scope. Therapeutic endoscope was withdrawn and a through-the-scope clip used to secure the proximal flange to the jejunal mucosa.
The therapeutic endoscope was withdrawn and the duodena scope advanced through the Axios stent to the second portion of the duodenum.
The major papilla was visualized. The major papilla was native. The major papilla had a bulging appearance.
The common bile duct was deeply cannulated after 1 attempt using a traction sphincterotome with 270 cm x 0.025" straight guidewire. No bleeding was observed
An initial contrast injection was performed successfully in the common bile duct. The injection extended throughout the biliary tree except the cystic duct. Ductal flow was adequate. The study's image quality was acceptable.
Generalized dilation was observed in the common bile duct with a maximal diameter of 20 mm with multiple filling defects consistent with choledocholithiasis.
Complete large biliary sphincterotomy was performed using a sphincterotome. No bleeding was noted at the procedure site.
Multiple sweeps were performed in the hepatic duct using a balloon, which was dilated from 12 mm to 18 mm with an ending size of 18 mm. Sludge, stones and debris were removed, achieving complete clearance.
Contrast injection with occlusion was performed successfully in the hepatic duct. The injection extended throughout the entire biliary tree. Ductal flow was adequate. The study's image quality was acceptable.
No stone or stricture was observed in the common bile duct.
The ERCP scope was withdrawn and the therapeutic endoscope reintroduced. The stent was in position.