bda23054
Networker
Please read the following Colonoscopy note. 45378 includes the decompression, but can I charge for the fluoroscopic guidance with this? I'm not finding a fluoro code that would go along with this. Any insight would be helpful. Thanks.
NAME OF OPERATIVE
1. Colonoscopy.
2. Placement of decompression tube under fluoroscopic guidance.
COMPLICATIONS
None.
INDICATIONS
The patient is a 68-year-old female who presented to the Emergency Department with the sudden onset and worsening sharp, crampy, abdominal pain since 1 o'clock in the afternoon. The patient's pain was controlled with pain meds. A CT scan was obtained showing concern for sigmoid volvulus with twisting of the mesentery. She was then scheduled for colonoscope decompression.
DESCRIPTION OF OPERATION
The patient was identified in the ER room. Her H&P was obtained. Description of the disease process was explained to the patient as well as the description of the colonoscopic decompression and decompression tube placement. The possibility of surgery was explained to the patient. She agreed to proceed. She was taken to the Operating Room and placed in the supine position. General anesthesia was then administered. She was then turned to the left lateral decubitus position. A digital rectal exam was performed showing no masses. The colonoscope was then inserted through the anus and into the rectum. There was a large amount of stool as it was an unprepped colon. The sigmoid colon was rather redundant and the scope was passed through easily until approximately the 110-cm mark. At this point there was a sharp twist and turn in the colon which took some time to pass the scope through. Once the scope was passed through, there was a large amount of large stool on the proximal side. At this point, a guide wire was placed through the scope and fluoroscopy was used to take an x-ray of this location. The scope was then removed over the guide wire leaving the guide wire in place. A decompression tube was then placed over the guide wire under fluoroscopic guidance. Once the tube was fully inserted, then the guide wire was removed. There was loose stool around the tube as well as through the tube at the end of the procedure. There were no complications. The patient tolerated the procedure well.
NAME OF OPERATIVE
1. Colonoscopy.
2. Placement of decompression tube under fluoroscopic guidance.
COMPLICATIONS
None.
INDICATIONS
The patient is a 68-year-old female who presented to the Emergency Department with the sudden onset and worsening sharp, crampy, abdominal pain since 1 o'clock in the afternoon. The patient's pain was controlled with pain meds. A CT scan was obtained showing concern for sigmoid volvulus with twisting of the mesentery. She was then scheduled for colonoscope decompression.
DESCRIPTION OF OPERATION
The patient was identified in the ER room. Her H&P was obtained. Description of the disease process was explained to the patient as well as the description of the colonoscopic decompression and decompression tube placement. The possibility of surgery was explained to the patient. She agreed to proceed. She was taken to the Operating Room and placed in the supine position. General anesthesia was then administered. She was then turned to the left lateral decubitus position. A digital rectal exam was performed showing no masses. The colonoscope was then inserted through the anus and into the rectum. There was a large amount of stool as it was an unprepped colon. The sigmoid colon was rather redundant and the scope was passed through easily until approximately the 110-cm mark. At this point there was a sharp twist and turn in the colon which took some time to pass the scope through. Once the scope was passed through, there was a large amount of large stool on the proximal side. At this point, a guide wire was placed through the scope and fluoroscopy was used to take an x-ray of this location. The scope was then removed over the guide wire leaving the guide wire in place. A decompression tube was then placed over the guide wire under fluoroscopic guidance. Once the tube was fully inserted, then the guide wire was removed. There was loose stool around the tube as well as through the tube at the end of the procedure. There were no complications. The patient tolerated the procedure well.