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Gastroenterology Coding Alert

Reader Question:

Pull Together $473 With Correct 45380 Use

Published on Fri Apr 01, 2011

Question: How should I bill a claim based on this medical report? PREOPERATIVE DIAGNOSIS: History of Crohn disease with nodularity and deformity of the ileocecal valve region now followed with colonoscopy. POSTOPERATIVE DIAGNOSES: Severe deformity of the ileocecal valve region with ileal stricture formation status post biopsy, separate polypoidal process appearing within the caput cecum in the periappendiceal region status post biopsy submitted in a separate container. SERVICE: Colonoscopy with biopsies PROCEDURE: After the patient was placed in the left lateral decubitus position, the doctor administered anesthesia until the patient was sedated. Once adequately sedated, the video pediatric colonoscope was introduced into the patient's rectum and advanced into the cecum. Cecal location was confirmed by characteristic architecture and transillumination in the right lower quadrant. Within the caput cecum in the periappendiceal region, a polypoidal process was noted. Biopsies were obtained. The instrument was withdrawn to the ileocecal valve area, which [...]
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