Help with coding!

mhart

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I am having an issue with coding this procedure. The patient had a Transrectal Ultrasound but the physician also used a scope to view the proximal bowel. When queried to find out what level of the bowel was viewed, he stated that 15 to 20 cm of the bowel was viewed up to the rectosigmoid junction which is at about 15cm. My question is would I use CPT 45300 - Proctosigmoidoscopy or 45341 - Sigmoidoscopy w/ ultrasound? Any feedback/information would be extremely helpful! Thank you!

OPERATION: Transrectal ultrasound.*
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BRIEF HISTORY: The patient is a 54-year-old woman who, on recent admission to the hospital for anemia and bleeding, was found to have a mid to proximal rectal cancer. It appears circumferential and, although narrowing the lumen, does not obstruct it completely. The patient has no obstructive symptoms. Preoperative CAT scan does not support metastatic disease. It does show wall thickening involving the proximal rectum with prominent perirectal lymph nodes. Additionally, the CAT scan of the chest shows only 2 very small nonspecific nodules in the lungs. Recommendation for a CAT scan in 6 months. Her CEA is 3.0. *
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She presents for a staging ultrasound.
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OPERATIVE FINDINGS: The patient was found to have a circumferential tumor that did narrow but did not obstruct the mid to proximal rectum. Images demonstrated invasion of the tumor through the wall of the bowel into the perirectal fatty tissue. Additionally, multiple lymph nodes were identified, at least 2 of which were greater than 1 cm in size. It is therefore staged as a UT3 N1 lesion.
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PROCEDURE: The patient was brought into the endoscopy suite and identified by the surgeon. Interval history and physical exam was reviewed. She was deemed appropriate for the intervention. She was placed in left lateral decubitus position and time-out was observed. *
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Digital rectal exam revealed mass palpable at the tip of the finger. It was moderately fixed in place. The ultrasound scope was then inserted and advanced under direct vision through the tumor into the more proximal bowel. The balloon was instilled with saline and then a careful slow pass was made through the rectal vault. *
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The above mentioned findings were noted. I should note that the tumor appeared circumferential, invasive into the perirectal fat, though I could not determine if it was, in fact, invasive into other structures in addition. *
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The scope was withdrawn, the patient tolerated the procedure well, and she was transported to the recovery room in stable condition.
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I don't know if I can help because I'm also confused about this, but I'll throw in my two cents and maybe it'll send you towards the best code to use.

Based on the actual documentation, I don't know if I'd code it as sigmoidoscopy because it doesn't seem that the examination went that far into the bowels. When I read the op note the first time, the portion where it states "... through the tumor into the more proximal bowel" I interpreted it as into the bowel more proximal (in direction) and not the proximal bowel itself. In other words, the scope went through the tumor and then a bit further, which leads me to a proctosigmoidoscopy. Then I wondered about the balloon being used; if it was instilled with saline and moved through the rectal vault, how could anything above that be examined? There's no mention of examining any further into the bowels.

I know the doctor provided information verbally, but I'm going off what the documentation says. Have you looked at 45303 Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie)? I have no idea if that would work, but I can't ignore the use of the balloon. :confused::confused:
 
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