proctosigmoidoscopy

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How would you code this report? Any help would be greatly appreciated

PREOPERATIVE DIAGNOSIS: Anorectal tumor.

POSTOPERATIVE DIAGNOSIS: Anorectal tumor.

PROCEDURES PERFORMED: Proctosigmoidoscopy, rectal exam under anesthesia, and multiple biopsies.

ANESTHESIA: General.

INDICATIONS FOR THE PROCEDURE: The patient is a 79-year-old gentleman who presented with pain and a mass effect in the anal area. He was found on examination to have rectal mass. He is now being brought in for examination under anesthesia and biopsies.

DETAIL OF THE PROCEDURE: The patient was taken to the operating room and placed in the supine position. He was given general anesthesia. He was repositioned in the lithotomy position. Examination revealed a large anterior anal tumor extending externally particularly in the left anterior position. This was little less than hemicircumferential. A proctosigmoidoscopy was done at 25 cm, which was otherwise unremarkable with no polyps, tumor, or inflammation, but he did have some internal hemorrhoids. The perianal area was prepped with Betadine scrub and paint and draped sterilely. Local anesthesia was also injected with 0.5% Marcaine with epinephrine. Again, examination revealed a large tumor. Several biopsies were done fairly deeply and sharply, and sent for histopathologic analysis. This did not look appropriate to excise this at this time as this could involve sphincter muscle etc., and this might proved to be a squamous cell process. The external aspects of this had look similar to condyloma. Hemostasis was achieved with electrocautery. The area was then cleaned and dressed completing the procedure, which the patient tolerated well and he was sent to the recovery room in stable condition.

PLAN: The patient will be discharged today. The patient was given instruction sheet upon discharge and was told to call for any problems at home. He will be seen in the office in the near future to discuss the findings and plan for the therapy.
 

Grintwig

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45305 maybe. (Proctosigmoidoscopy, rigid; with biopsy, single or multiple)
Per CPT guidelines a surgical endoscopy always includes a diagnostic endoscopy and you can not bill the rectal exam itself with this code as it is included.
 

acbarnes

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I would be careful...did he actually do the biopsies with the proctosigmoidoscope? I bet he used the proctosigmoidoscope to exam the rectum to make sure there were no other tumors, masses, etc further up, then removed the scope, then performed incisional biopsies using a speculum. If so you might want to look at 45100;otherwise 45305 proctosigmoidoscopy w/bx is correct.

Anna Barnes, CPC, CEMC, CGSCS
 
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