Samantha818
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Provider billed 44376 - small bowel endoscopy and 45380 colonoscopy
Operative reads:
Indications for Procedure:
Surveillance colonoscopy status post resection for colon cancer.
Procedure and Findings:
The patient was brought into the colonoscopy suite, placed in left lateral decubitus postion, conscious sedation was induced and she was kept on a monitor. Digital rectal examination was then performed, which was normal. We then introduced our colonoscope into the anal canal and into the rectum where we began insufflation. There was good visualization. The quantity of the prep was average. The colonoscope was then advanced into the sigmoid colon, which was very tortuous and difficult. The patient had a moderate diverticulosis without active inflammation and the colonoscope was then advanced with some degree of difficulty into the transverse colon. Once we were beyond the transverse colon, we identified anastomosis from her previous resction at the level of the ileum. The colonoscope was introduced into the terminal ileum and the muscosa here was normal. We then withdrew our colonoscop in order to inspect the anastomosis. There was no evidence of stricture or recurrence. We identified the staples intact and the anastomosis was in good condition. We then began to withdraw the colonoscope slowly examining the muscosa as we withdrew. At the level of the sigmoid colon, there was an approximately 2mm polyp, which was red in color. We performed an excisional biopsy of this polyp, two speciments were sent to pathology for review. The scope was then withdrawn into the rectum with no other abnormalities. The scope was retroflexed and there was some internal hemorrhoids noted. The scope was then withdrawn, air was desuffated. The patient tolerated the procedure well.
Question: are the codes justified.
I believe only 45380 is valid. The doctor believes both 45380 and 44376 are supported.
Please comment.
Operative reads:
Indications for Procedure:
Surveillance colonoscopy status post resection for colon cancer.
Procedure and Findings:
The patient was brought into the colonoscopy suite, placed in left lateral decubitus postion, conscious sedation was induced and she was kept on a monitor. Digital rectal examination was then performed, which was normal. We then introduced our colonoscope into the anal canal and into the rectum where we began insufflation. There was good visualization. The quantity of the prep was average. The colonoscope was then advanced into the sigmoid colon, which was very tortuous and difficult. The patient had a moderate diverticulosis without active inflammation and the colonoscope was then advanced with some degree of difficulty into the transverse colon. Once we were beyond the transverse colon, we identified anastomosis from her previous resction at the level of the ileum. The colonoscope was introduced into the terminal ileum and the muscosa here was normal. We then withdrew our colonoscop in order to inspect the anastomosis. There was no evidence of stricture or recurrence. We identified the staples intact and the anastomosis was in good condition. We then began to withdraw the colonoscope slowly examining the muscosa as we withdrew. At the level of the sigmoid colon, there was an approximately 2mm polyp, which was red in color. We performed an excisional biopsy of this polyp, two speciments were sent to pathology for review. The scope was then withdrawn into the rectum with no other abnormalities. The scope was retroflexed and there was some internal hemorrhoids noted. The scope was then withdrawn, air was desuffated. The patient tolerated the procedure well.
Question: are the codes justified.
I believe only 45380 is valid. The doctor believes both 45380 and 44376 are supported.
Please comment.