NESmith
Expert
Please advise:
Procedure-Patient presents for an elective colonoscopy.
Indications: Screening
Consent: the benefits, risks, and alternatives to the procedure were discussed and informed consent was obtained from the patient.
Preparation: EKG, pulse, pulse oximetry, and blood pressure were monitired throughout the procedure. Patient verified, procedure verified, position noted.
Rectal Exam: Mormal rectal exam
Procedure: The colonoscopy was passed through the anus under direct visualization and was advanced wwith ease to the cecum. The scope was withdrawn and the mucosa was carefully examined. The quality of the preparation was good. the views were good. Sclerotherapy was injected to destroy hemorrhoids. Good hemostasis.
Findings: A single polyp was found in the ascending colon. A cold forceps biospy was taken. Grade I hemorrhoids were found.
Unplanned Events: There were no unplanned events.
Endoscopic Impression: A single polyp was found in the ascending colon(211.3). Biospy taken.
Grade I hemorrhoids found(455.6).
Recommendations: F/U appointment with endoscopist in 2 weeks.
Provider wantes to bill CPT code 45383.
I think it should be CPT code 45380.
Thank You for your help in this matter.
Procedure-Patient presents for an elective colonoscopy.
Indications: Screening
Consent: the benefits, risks, and alternatives to the procedure were discussed and informed consent was obtained from the patient.
Preparation: EKG, pulse, pulse oximetry, and blood pressure were monitired throughout the procedure. Patient verified, procedure verified, position noted.
Rectal Exam: Mormal rectal exam
Procedure: The colonoscopy was passed through the anus under direct visualization and was advanced wwith ease to the cecum. The scope was withdrawn and the mucosa was carefully examined. The quality of the preparation was good. the views were good. Sclerotherapy was injected to destroy hemorrhoids. Good hemostasis.
Findings: A single polyp was found in the ascending colon. A cold forceps biospy was taken. Grade I hemorrhoids were found.
Unplanned Events: There were no unplanned events.
Endoscopic Impression: A single polyp was found in the ascending colon(211.3). Biospy taken.
Grade I hemorrhoids found(455.6).
Recommendations: F/U appointment with endoscopist in 2 weeks.
Provider wantes to bill CPT code 45383.
I think it should be CPT code 45380.
Thank You for your help in this matter.