Question about Colonoscopy

tholcomb

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Good afternoon Fellow Coders,

I have a patient who came in for colonoscopy the indication was followup for piecemeal resection below is the copy of the report the patient had a colonoscopy done on 8-9-13 for hx of polyp V12.72 and had the one below on 12-20-13 another coder submitted 45380 and 45385 w/ dx 211.3 and this was denied any suggestions?

Thank you,
TH

Followup of piecemeal resection

Procedure: The endoscope was passed with ease through the anus under
direct visualization and advanced to the cecum, confirmed by appendiceal
orifice, cecal strap (crow's foot), and ileocecal valve. The scope was
withdrawn and the mucosa was carefully examined. The quality of the
preparation was good. The patient's toleration of the procedure was
excellent. The views were excellent.

Findings: Patient known to have multiple sessile serrated adenoma. At the
site of the prior large sessile serrated adenoma the spot dye was seen and
was free of any evidence of dysplasia at this time. The prior colonoscopy
had had a suboptimal prep and another flat appearing polyp was seen in the
proximal transverse colon that was at least 4 cm in diameter. It was first
injected submucossaly with indigo carmine and saline in an attempt to
delineate its edges. It lifted well. Then it was piecemeal resected under
endocut settings using a captivator snare and APC applied to the resection
margins. Then 4 clips were placed at the polypectomy site. THis large
polyp was 15 cm distal to the prior marked polypectomy site. An
additional diminutive appearing polyp in the transverse colon of 4 mm was
removed with cold forceps.

Complications: There were no complications.

Impression: Large flat appearing polyp with nbi features consistent with
sessile serrated or conventional adenomatous polyp. It was removed in
piece meal fashion with APC of edges and clips applied.

Recommendations: repeat colonoscopy in 6 months resume regular diet as
tolerated.
 

sheardmd

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I would have used a -59 on the 45380, otherwise I don't see anything else that I would have done differently.
 
Last edited:

Kerly F

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Why is another colonoscopy done 4 months apart? The polyps should have been resected on the one in August
 
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