mhcpc
Guru
Help! One of my physicians supplied me with a charge sheet that says 45380 and 44391. This is the documentation he provided.
Pre-procedure Diagnoses
1. CROHN'S DISEASE OF SMALL INTESTINE (555.0)
Post-procedure Diagnoses
1. CHRONIC GI BLEEDING (578.9)
Procedures
1. COLONOSCOPY THRU STOMA,W/CONTROL,BLEED (44391)
2. COLONOSCOPY,BIOPSY (45380)
Premed: 75 mg demerol IV
4 mg versed IV
PCFQ180AL introduced into rectum and passed through the ieolcolic anastomosis into the ileum. Anastomosis around 30 cm from anus.
Prep was poor with formed stool in colon and coming down from small bowel despite bowel prep on top of gastroenteritis.
Had to roll pat supine to cause stool to roll away from anastomosis to visualize it.
There was active bleeding from a dozen or so3-4 mm nodules with exudate at the tip. These were evenly distributed in a circular pattern around approximately 15% of the circumference of the ileo colostomy on the colonic edge. 4 biopsies were taken and the nodules were cauterized with IRBE which did not result in cessation of bleeding from the biopsy sites.
Assessment: oozing from nodules at ileo-colostomy which were cauterized.
Appearance is more consistent with stitch granulomas that with Crohn's.
Plan: If cautery fails to slow bleeding and IBD serologies are negative, we should probably consider surgical resection and reanastomosis.
Pre-procedure Diagnoses
1. CROHN'S DISEASE OF SMALL INTESTINE (555.0)
Post-procedure Diagnoses
1. CHRONIC GI BLEEDING (578.9)
Procedures
1. COLONOSCOPY THRU STOMA,W/CONTROL,BLEED (44391)
2. COLONOSCOPY,BIOPSY (45380)
Premed: 75 mg demerol IV
4 mg versed IV
PCFQ180AL introduced into rectum and passed through the ieolcolic anastomosis into the ileum. Anastomosis around 30 cm from anus.
Prep was poor with formed stool in colon and coming down from small bowel despite bowel prep on top of gastroenteritis.
Had to roll pat supine to cause stool to roll away from anastomosis to visualize it.
There was active bleeding from a dozen or so3-4 mm nodules with exudate at the tip. These were evenly distributed in a circular pattern around approximately 15% of the circumference of the ileo colostomy on the colonic edge. 4 biopsies were taken and the nodules were cauterized with IRBE which did not result in cessation of bleeding from the biopsy sites.
Assessment: oozing from nodules at ileo-colostomy which were cauterized.
Appearance is more consistent with stitch granulomas that with Crohn's.
Plan: If cautery fails to slow bleeding and IBD serologies are negative, we should probably consider surgical resection and reanastomosis.