clwilliamson
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I am new to gastro coding and need assistance with this op report. Would I code this as 43274? Would a modifier be needed?
Thanks!
PROCEDURE: ERCP, placement of a pancreatic stent, removal of a pancreatic stent.
REPORT: We attempted the ERCP initially with the patient in the prone position, using the Exalt disposable duodenoscope. This
could not be passed through the oropharynx. We placed the patient onto her left side, and still were unable to place the Exalt
duodenoscope.
We were able to pass the adult endoscope into the duodenum, and she had evidence of a significant and severe duodenitis, with a
number of duodenal superficial ulcers, erythema and edema.
The endoscope was withdrawn.
We then used the standard duodenoscope. I was able to place this into the duodenum with no difficulty. The small ampulla sat on the
fringe of a small duodenal diverticulum.
We were able to obtain a pancreatogram.
Thereafter, attempts at obtaining selective biliary cannulation were unsuccessful.
We were able to place a pancreatic stent, to possibly help facilitate biliary access, but this was unsuccessful.
After trials of different catheters and wires and being unsuccessful and being uncertain as to the anatomy and performing a precut
sphincterotomy, the procedure was terminated.
IMPRESSION: Unable to pass the Exalt disposable duodenoscope through the oropharynx.
Panendoscopy with the adult endoscope showing evidence of significant duodenal bulb ulcer disease as described.
Completion of the ERCP using the standard duodenoscope.
Pancreatogram which was normal.
Placement of a pancreatic stent, 3 cm in length, 4 mm in diameter.
Despite the placement of the pancreatic stent, unsuccessful biliary cannulation. Multiple attempts as described above.
Thanks!
PROCEDURE: ERCP, placement of a pancreatic stent, removal of a pancreatic stent.
REPORT: We attempted the ERCP initially with the patient in the prone position, using the Exalt disposable duodenoscope. This
could not be passed through the oropharynx. We placed the patient onto her left side, and still were unable to place the Exalt
duodenoscope.
We were able to pass the adult endoscope into the duodenum, and she had evidence of a significant and severe duodenitis, with a
number of duodenal superficial ulcers, erythema and edema.
The endoscope was withdrawn.
We then used the standard duodenoscope. I was able to place this into the duodenum with no difficulty. The small ampulla sat on the
fringe of a small duodenal diverticulum.
We were able to obtain a pancreatogram.
Thereafter, attempts at obtaining selective biliary cannulation were unsuccessful.
We were able to place a pancreatic stent, to possibly help facilitate biliary access, but this was unsuccessful.
After trials of different catheters and wires and being unsuccessful and being uncertain as to the anatomy and performing a precut
sphincterotomy, the procedure was terminated.
IMPRESSION: Unable to pass the Exalt disposable duodenoscope through the oropharynx.
Panendoscopy with the adult endoscope showing evidence of significant duodenal bulb ulcer disease as described.
Completion of the ERCP using the standard duodenoscope.
Pancreatogram which was normal.
Placement of a pancreatic stent, 3 cm in length, 4 mm in diameter.
Despite the placement of the pancreatic stent, unsuccessful biliary cannulation. Multiple attempts as described above.