barb.boek@gmaial.com
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Need help with this one please,not sure If I can bill the control of bleeding?
In the cecum, a sessile polyp in the appendiceal orifice was
seen. The polyp was not bleeding. The polyp was adenomatous in
appearance. The base was injected with saline to lift the polyp
and the polyp was excised in piecemeal fashion by snare with
cautery followed by hot biopsy then cold biopsy. The polyp was
retrieved.
In the proximal ascending colon, a sessile polyp 4 mm in diameter
was seen in the proximal ascending colon. The polyp was not
bleeding. The polyp was adenomatous in appearance. The polyp
was completely excised by cold excisional biopsy. The polyp was
retrieved.
In the proximal descending colon, the first polyp, a flat polyp 4
mm in diameter was seen. The polyp was not bleeding. The polyp
was adenomatous in appearance. The polyp was completely excised
by snare with cautery. The polyp was retrieved. The second
polyp, a sessile polyp 8 mm in diameter was seen. The polyp was
not bleeding. The polyp was adenomatous in appearance. The
polyp was completely excised by snare with cautery in piecemeal
fashion. The polyp was retrieved.
In the proximal sigmoid colon, a partially obstructing,
large-size, fungating, friable, infiltrative, malignant appearing
mass was seen at about 60 cm from the anus. The mass was
actively bleeding. Area was injected with total of 8cc India ink
for tattooing both proximal and distal to the mass.
In the rectum, a few medium-size internal hemorrhoids were seen.
The internal hemorrhoids were not bleeding.
At the rectosigmoid junction, a pedunculated polyp 10 mm in
diameter was seen. The polyp was not bleeding. The polyp was
adenomatous in appearance. The polyp was completely excised by
snare with cautery. The polyp was retrieved. Due to the stalk
size and some post-polypectomy oozing, the area was injected with
1 cc of 1:10000 epinephrine and clipped with 3 resolution clips.
The colon was otherwise normal.
If so I was going to bill
45382-59
45385
45380-59
45381-51
TIA
BB
In the cecum, a sessile polyp in the appendiceal orifice was
seen. The polyp was not bleeding. The polyp was adenomatous in
appearance. The base was injected with saline to lift the polyp
and the polyp was excised in piecemeal fashion by snare with
cautery followed by hot biopsy then cold biopsy. The polyp was
retrieved.
In the proximal ascending colon, a sessile polyp 4 mm in diameter
was seen in the proximal ascending colon. The polyp was not
bleeding. The polyp was adenomatous in appearance. The polyp
was completely excised by cold excisional biopsy. The polyp was
retrieved.
In the proximal descending colon, the first polyp, a flat polyp 4
mm in diameter was seen. The polyp was not bleeding. The polyp
was adenomatous in appearance. The polyp was completely excised
by snare with cautery. The polyp was retrieved. The second
polyp, a sessile polyp 8 mm in diameter was seen. The polyp was
not bleeding. The polyp was adenomatous in appearance. The
polyp was completely excised by snare with cautery in piecemeal
fashion. The polyp was retrieved.
In the proximal sigmoid colon, a partially obstructing,
large-size, fungating, friable, infiltrative, malignant appearing
mass was seen at about 60 cm from the anus. The mass was
actively bleeding. Area was injected with total of 8cc India ink
for tattooing both proximal and distal to the mass.
In the rectum, a few medium-size internal hemorrhoids were seen.
The internal hemorrhoids were not bleeding.
At the rectosigmoid junction, a pedunculated polyp 10 mm in
diameter was seen. The polyp was not bleeding. The polyp was
adenomatous in appearance. The polyp was completely excised by
snare with cautery. The polyp was retrieved. Due to the stalk
size and some post-polypectomy oozing, the area was injected with
1 cc of 1:10000 epinephrine and clipped with 3 resolution clips.
The colon was otherwise normal.
If so I was going to bill
45382-59
45385
45380-59
45381-51
TIA
BB