I would code this 44394, 44385. This is a first for me so I am not 100% sure. Any suggestions? Thanks in advance
PROCEDURE PERFORMED: Colonoscopy and pouchoscopy.
INDICATION: Average risk colorectal cancer screening.
MEDICATIONS: Versed 3 mg IV, Fentanyl 75 mcg IV.
COMPLICATIONS: There were no obvious complications.
TECHNIQUE: After informed written consent was obtained and after procedure
time out had been performed the patient was placed on her back and moderate
sedation was administered. The colonoscope was then advanced into her
ostomy in the left lower quadrant with the aide of direct visualization.
Colonoscope was then advanced the cecum and then carefully withdrawn with
the mucosa being carefully examined. The scope was withdrawn through the
end of her ostomy and then the patient was placed in the left lateral
decubitus position. Her rectal pouch was then examined under the aide of
1. Cecal polyp measuring 6 mm status-post hot snare polypectomy.
2. Normal colonic mucosa except for scattered diverticuli on both
residual left and right colon.
3. Rectal pouch measuring 15 cm had mild erythema and slightly nodular
appearance in the area status-post cold biopsy x 2.
1. Followup pathology.
2. Repeat in 5 years.
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