Colonoscopy Removed and Replaced with Upper Endoscope
I'm new to colonoscopy coding and i am having a hard time coding this procedure:
Indications: Average-risk screening, pain centered in the left upper quadrant of the abdomen, constipation.
Procedure: The endoscope was passed with great difficulty through the anus under direct visualization and advanced to the ascending colon, confirmed by landmarks, trans illumination, photographs, and ileocecal valve. The patient required counter pressure, positioning on the back, and right side down positioning to aid in the passage of the scope. The scope was withdrawn and the mucosa was carefully examined. The quality of the preparation was good. Retroflexion was performed in the rectum.
Findings: There was no evidence of angioectasia/AVM, ulcerated mucosae, tumors, or polyps in the colon. On retroflexed view, small internal hemorrhoids were found. The hemorrhoids showed no bleeding stigmata. There was evidence of severe diverticulosis in the sigmoid colon and descending colon. Of note, the colonoscope could not be passed beyond 30 cms because of extreme tortuosity. It was removed and replaced with an upper endoscope which was able to be advanced into right colon by careful manipulation, position changes and external pressure.
I am not sure about this, but this is what i have:
Any help is greatly appreciated. Thank you.
Haidee Graves, COC, CPC
2016 Member Development Officer
Kalispell, MT Chapter