Op Report - Colonoscopy

[KoBee]

Sometimes I get confused on what is appropriate documentation, but we have a provider who set ups his documentation in a way where you are just naming the procedure and not a detail procedure of findings.

Can anyone read this and tell me if you agree with documentation the way its set up or written. Are we okay to just go ahead and code of the findings?


Rectal exam performed and no acute pathology.The Fujion video colonoscope was introduced through the anus,rectum, sigmoid colon,descending colon, transverse colon, ascending colon up to the cecum under direct visualization. The cecum was identified by the iliocecal valve and the appendiceal orifice. Prep was Good. Semisolid and liquid stools seen throughout. Vigorous lavage performed with good views of the mucosa. As the scope was withdrawn the mucosa was carefully examined. Cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum were visualized. In the rectum the scope was retroflexed and the rectal vault appeared normal.

Cecal intubation time: 9 minutes
Withdrawal time: 11 minutes

Findings:
1. 4 mm sessile polyp cecum (CS)
2. 2 mm colon polyp (CF)

ASSESSMENT:
1. Colon polyps. 2 removed. Largest 4 mm.

 

[kdlberg]

As far as description of the visualization, I think this is okay. But the findings should be a part of the narrative (i.e., "scope advanced to cecum, polyp seen.") Also, shouldn't there be a description of how the polyps were removed? I'm an office coder, but I've seen my share of colonoscopy documentation, and I'm 90% certain that's usually in there.