Wiki Colonoscopy help please

[lindacoder]

Medicare patient underwent colectomy 11-12-10

DOS: 3-16-11
PREOP DIAGNOSIS: Possible stricture of rectal anastomosis.
POSTOP DIAGNOSIS: Stricture of the area of the rectal anastomosis with no identifiable lumen.
OPERATION: Colonoscopy

INDICATIONS: This patient had a previous GI series of her lower tract. With barium, she was found to have a stricture at the rectosigmoid junction. This was felt to be fairly significant. For this reason, a colonoscopy is performed to see if we need to dilate this prior to taking down her ileostomy.

OPERATIVE PROCEDURE: Under satisfactory prep with the patient sedated, the colonoscope was inserted in the anus. This was advanced to about 15-20 cm some fecal material was present. This was evacuated with the evacuator. After evacuating this, I could not find a lumen which can be cannulated or ballooned. Extensive attempts at cannulating the rectal stump or looking at this area did not reveal any openings. After about 15 minutes of trying this, the procedure was terminated. I believe the patient has a significant stricture of the rectosigmoid junction which would make it unsafe to close her ileostomy at this time. I will discuss further options with the family.

Any ideas for CPT and ICD9??

Thanks

 

[rebmcdow]

colonoscopy

the CPT code that you could use would be 45378 with the modifier 53 because the procedure was discontinued after 15 minutes. The cide the icd code as a rectum stricture or the rectosigmod stricture. Hope this helps,remember the colonoscopy did not take a biopspy or controlled bleeding.

 

[blathrop19@gmail.com]

Do you code for the physician or the facility? Because I believe that can play a role in the modifier.

 

[lindacoder]

this is for the physician only