THE CODING EDGE® ARCHIVES

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Coding Recommendations - Feature Article 05/15/98
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" operative report.

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Preoperative Diagnosis:
Multiple colonic polyps. Rectal bleeding.

Postoperative Diagnosis:
Multiple colonic polyps. Hemorrhoids.

Procedure:
Colonoscopy with polypectomy. Hemorrhoid ablation.

Description of Procedure: After appropriate IV sedation and with the patient in the left lateral decubitus position, the video colonoscope was introduced per rectum through a tortuous right colon and advanced with minimal difficulty to the cecum. Bowel preparation was adequate. The cecum was well visualized and appeared normal. The entire length of the bowel was carefully examined upon slow and methodical withdrawal of the scope.

A small sessile polyp was noted in the transverse right colon. This was easily removed with the cautery snare and sent for pathology. The remainder of the transverse colon appeared normal.

A second polyp measuring approximately 8 cm in diameter was noted approximately 45 cm from the anal verge. It was removed with the snare, labeled as specimen #2, and sent for pathological examination. At the rectosigmoid junction another very small polyp was noted. This lesion was cauterized and obliterated with no specimen retrievable for pathology.

Internal hemorrhoids were seen as the scope was removed. Evidence of recent active bleeding was noted in the 3 o'clock position. The scope was withdrawn and the bleeding sites were coagulated with the laser unit. The patient tolerated the procedure well.

      

     

Using the above samples, do your own coding and then compare it with our recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.
 

 

Please be aware that the Coding Edge® Archive pages are NOT retroactively updated
to reflect possible coding rules and regulation changes made after the publishing date.