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General Surgery Coding Alert

Reader Question:

Incomplete TIF Reverts to EGD

Published on Thu Nov 15, 2012

Question: Our surgeon performed an EGD with intention to complete a TIF procedure. Here's a portion of the note:"The scope was advanced down the posterior pharynx into the esophagus, through the GE junction into the stomach. Retroflexion revealed that the patient appeared to have adequate amount of stomach so that the TIF could be performed. The retroflex was reversed and scope was advanced through the pylorus into the duodenum for exam. The scope was then withdrawn.The scope was then placed through EsophyX device and advanced into the mouth via the bite block. The posterior pharynx was negotiated and the scope and the device were then advanced under direct visualization into the stomach. At this time, even with multiple manipulations, I was unable to be able to close the device safely to create the fundoplication, and the decision was made to abort the TIF." How should I code the scenario?New York [...]
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