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Exam under anesthesia w/removal of colon ring, sigmoidoscopy

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lindacoder

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Northeast Kansas AAPC
I am thinking this is just a sigmoidoscopy 45330 and EUA w/removal of foreign body 46608.
Anal area was prepped and draped. Approximately 8 cm up you could feel the colon ring. There was stricturing below it. I was able to dilate this up, place a tenaculum on this colon ring and remove it. After removing it we did a sigmoidoscopy. Posteriorly you could tell the area had sort of eroded through probably where the ring was resting and mucosa raw. Did a sigmoidoscopy and was able to go up through the anastomosis. It is tightly strictured and I dilated that up and I could get a little over a finger and a half through this anastomosis. --- Didn't think I could use 45340 as no mention of balloon was described.

Thanks
 
What about 45915, just removal of foreign body since anoscope not mentioned? Now 45915 and 45330 are a NCCI edit so you cannot bill both. I would bill 45915 since it has a higher facility RVU(5.49) versus 45330 with fac RVU 1.67. Also, sigmoidoscope used more to evaluate the site than diagnose. Just a thought.

Anna Barnes, CPC, CGSCS
 
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