I am in need of help coding an inpt procedure - PT was seen for a colonic pseudo obstruction.
Op Note: Scope advance into left side of colon - large firm stool balls were impacted in the left colon in an area of significant colitis with erythema and edema seen. With aggressive irrigation and suctioning and use of a Roth net to remove some of these stool balls the area was decompressed and the colonoscope was able to advance to the right colon (likely to the area of the of hepatic flexure or ascending colon) The right side of the colon was significantly distended with air and liquid stool. Extensive suctioning was preformed removing almost two liters of liquid stool. Her abdominal exam improved significantly with sort abdomen at this point. Additional biopsies were taken in areas with significant erythema and edema.
I know that I need to bill 45380 for the colon w/biopsies but how do I bill the decompression & fecal impaction? Please help......
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