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Gastroenterology Coding Alert

Reader Questions:

45383, 45380: Resolve Your Colonic Hemorrhage Doubts

Published on Tue Mar 08, 2011

Question: Our gastroenterologist diagnosed a patient with significiant lower gastrointestinal bleed status post polypectomy of the ascending colon a day ago. He observed bleeding at the polypectomy area of proximal ascending colon. How should I report this case based on the following physician's note? Digital rectal examination was performed, after which the PCF160 video colonoscope was inserted into the rectum and advanced to the cecum. There was old blood throughout the whole colon. In the area of the proximal ascending colon, the site of the previous polypectomy was visualized with fresh clot hanging out, with drops of blood coming out under the clot. Those findings confirmed. The epinephrine injection submucosally was performed; first circumferentially at the polypectomy site. This arrested the bleeding. Now the clot was removed with cold biopsy forceps and the base of the polypectomy site was treated with Argon plasma coagulator. A nice eschar was achieved and [...]
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