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Endorectal ultrasound

  1. #1
    Default Endorectal ultrasound
    Medical Coding Books
    I cannot find a code for endorectal ultrasound. Based on this report I came up with the following codes: 45335, 45305 (the scope only went to about 15 cm). Any guidance would be greatly appreciated. Thanks.




    INDICATIONS: RECTAL MASS: THIS 52-YEAR-OLD GENTLEMAN IS REFERRED FOR
    ENDORECTAL ULTRASOUND AFTER A COLONOSCOPY LAST WEEK SHOWED A MALIGNANT
    POLYP AT 25 CM, AND A LARGE TUBULOVILLOUS ADENOMA IN THE RECTUM. I AM NOW
    ASKED TO ASSESS FOR INVASION.

    THE PROCEDURES, A FLEXIBLE SIGMOIDOSCOPY AND AN ENDORECTAL ULTRASOUND, WERE
    EXPLAINED TO THE PATIENT, WITH POTENTIAL RISKS AND COMPLICATIONS INVOLVED.
    ALL QUESTIONS WERE ANSWERED. THE PATIENT GAVE INFORMED CONSENT TO THE
    PROCEDURES.

    TECHNIQUE AND FINDINGS: THE ADULT GASTROSCOPE WAS INSERTED THROUGH THE
    RECTUM, AND ADVANCED UNDER INSUFFLATION TO ABOUT 40 CM. THE PREP WAS VERY
    GOOD. AROUND 25 TO 30 CM, THE PREVIOUS POLYPECTOMY SITE IS NOTED, AND SPOT
    INK INJECTIONS ARE PERFORMED ON SEVERAL LOCATIONS OF THE COLON AROUND THE
    POLYPECTOMY SITE FOR SURGICAL MARKING.

    ON FURTHER WITHDRAWAL IN THE RECTUM THEN, PRIMARILY SEEN ON RETROFLEX EXAM,
    IS A LARGE, 3 TO 4-CM POLYP. THE AIR IS REMOVED AND THE INSTRUMENT
    WITHDRAWN.

    AFTER REMOVAL OF THE GASTROSCOPE, THE RADIAL ECHOENDOSCOPE IS INSERTED
    THROUGH THE RECTUM AND ADVANCED TO ABOUT 15 CM. THE BALLOON IS INSUFFLATED
    WITH WATER AND THEN, ON SLOW WITHDRAWAL OF THE INSTRUMENT, THE ULTRASOUND
    PROPERTIES ARE NOTED. THE ILIAC VESSELS ARE IDENTIFIED. THE PROSTATE
    SHOWS SOME MINOR CALCIFICATIONS, ALTHOUGH IT DOES NOT APPEAR TO BE
    ENLARGED. SEMINAL VESICLES ARE ALSO NORMAL.

    IN THE MID-RECTUM, A LARGE POLYPOID, MUCOSAL-BASED LESION IS NOTED. THE
    MUSCULARIS PROPRIA APPEARS INTACT THROUGHOUT THE ENTIRE RECTUM, AND NO
    EVIDENCE OF INVASION IS SEEN. BEHIND THE POLYP, A 9-MM ROUND, OVOID LYMPH
    NODE IS SEEN. THE AIR IS REMOVED. AFTER WITHDRAWAL OF THE BALLOON, THE
    INSTRUMENT IS REMOVED.

    THE PATIENT TOLERATED THE WHOLE PROCEDURE WELL.

    IMPRESSION:
    1. RECTAL MASS, NO INVASION INTO THE MUSCULAR PROPRIA OR BEYOND IS
    NOTED.
    2. PREVIOUS POLYPECTOMY SITE AT 25 CM, INJECTED WITH SPOT INK
    JOJO-CPC-H

  2. #2
    Default
    Look at the flex sig ultrasound code, 45341 with a 52 modifier in addition to the 45335; they are not bundled. The claim will need a concise explanation in the field for box 19 describing the nature of the reduced service.
    Jenny Berkshire, CPC, CEMC, CGIC

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