jojogi
Guest
Help! After reading this note I want to code 44388, 45331-51 but I am not sure. If someone could give me their insight, I would really appreciate it. Thanks 
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INDICATION: Abnormal gastrografin enema. Recent diversion procedure for
dilated colon.
TECHNIQUE: After obtaining informed written consent the patient he was
placed in the supine position. Moderate sedation was administered.
Standard monitoring was performed throughout the procedure. Under direct
visualization the scope was pass through the ostomy and into the cecum.
The prep was just fair. The ileocecal valve and appendiceal orifice were
seen. On withdrawal of the scope there were no obvious lesions but the
prep was just fair. The scope was withdrawn and went through the second
ostomy site for approximately 30-40 cm at which time the scope could no
longer be passed, but the prep was just fair. In this region there was no
obvious lesion. The scope could not traverse a tight narrowing but there
was no mass seen. The scope was then withdrawn and out the ostomy. A
rectal exam was then performed which showed no obvious lesions. The scope
was the inserted and advanced approximately 90 cm whereby the light could
be seen through the ostomy rite at the stoma site. The scope could not be
completely traversed and was very narrowed at the distal ending. The scope
was then withdrawn and at approximately 55 cm until about 20 cm the colonic
folds were thickened and edematous. There was some mild inflammation seen
and biopsies were taken and placed in jar #1. Retroflexion was performed
which showed no masses or lesions.
FINDINGS:
IMPRESSION:
1. No obvious cause of dilated colon nor mass or lesion seen.
2. There was a narrowing when the scope was passed down the stoma as
well as going retrograde via the rectum; however, there was no mass
or lesion seen.
3. Thickened folds status-post biopsy and placed in jar #1, likely from
his anasarca and poor nutritional status. May also be related to
diversion colitis.
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INDICATION: Abnormal gastrografin enema. Recent diversion procedure for
dilated colon.
TECHNIQUE: After obtaining informed written consent the patient he was
placed in the supine position. Moderate sedation was administered.
Standard monitoring was performed throughout the procedure. Under direct
visualization the scope was pass through the ostomy and into the cecum.
The prep was just fair. The ileocecal valve and appendiceal orifice were
seen. On withdrawal of the scope there were no obvious lesions but the
prep was just fair. The scope was withdrawn and went through the second
ostomy site for approximately 30-40 cm at which time the scope could no
longer be passed, but the prep was just fair. In this region there was no
obvious lesion. The scope could not traverse a tight narrowing but there
was no mass seen. The scope was then withdrawn and out the ostomy. A
rectal exam was then performed which showed no obvious lesions. The scope
was the inserted and advanced approximately 90 cm whereby the light could
be seen through the ostomy rite at the stoma site. The scope could not be
completely traversed and was very narrowed at the distal ending. The scope
was then withdrawn and at approximately 55 cm until about 20 cm the colonic
folds were thickened and edematous. There was some mild inflammation seen
and biopsies were taken and placed in jar #1. Retroflexion was performed
which showed no masses or lesions.
FINDINGS:
IMPRESSION:
1. No obvious cause of dilated colon nor mass or lesion seen.
2. There was a narrowing when the scope was passed down the stoma as
well as going retrograde via the rectum; however, there was no mass
or lesion seen.
3. Thickened folds status-post biopsy and placed in jar #1, likely from
his anasarca and poor nutritional status. May also be related to
diversion colitis.