Wiki Coding help please!!!

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magmae

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Colonoscopy for Crohn's.....Report states:

introduced through the ileostomy and andvanced to the terminal ileum. colonoscopy performed without difficulty. A TTS dilator was passed through the scope. Dilation with a 6-7-8mm x 5.5cm CRE balloon dilator was performed. Distal ileum contained a single 10mm ulcer that was biopsied with cold forceps. Remained of exam to the terminal ileum was normal. Random biopsies taken.

Any help as to which codes to bill would be greatly appreciated. Thanks
 
..."through ileostomy"...so was it a colonoscopy through a stoma?
If so, then it would be 44389 for the cold biopsy. No stoma code for the dilation that I can find - you could use the unlisted 44799 and then attach/fax/send/etc. the op note for the unlisted code.
If it was a 'normal' colonoscopy through the rectum, then you would use coach's codes.
 
thanks... yes, through ileostomy... I was leaning towards the 44389 for the biopsy but was also looking at the 45386 for the dialator since a 'colonoscopy' was done and when googled colonoscopy through ileostomy/tts dilator cpt that is what came up....Any ideas?
 
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