vmounce
Guru
I Want to get other thoughts on this operative report. See below. My question to this is: Should I bill for the balloon dilitation and the savory. My thoughts are just bill savory(43248) and since balloon dilatation was not achieved I would not bill this. I bill for ASC and doctors office for the doc. The doctors office is using both 43248 and 43249. I appreciate any info.
Vickie Mounce
PREOPERATIVE DIAGNOSIS: Esophagitis with history of stricture and persistent dysphagia.
POSTOPERATIVE DIAGNOSES:
Esophagitis.
Mild elongated esophageal stricture.
PROCEDURE: Esophagogastroduodenoscopy with esophageal biopsies and esophageal dilatation.
OPERATIVE PROCEDURE: Following informed consent, the patient was placed in the left lateral decubitus position and general anesthesia was administered. The scope was then passed under direct visualization through the oropharynx and into the esophagus. The esophagus had a mildly erythematous appearance with a thin layer of whitish exudative material. There was a trabeculated appearance of the mucosa diffusely. In the distal third of the esophagus, there was subtle decrease in the luminal caliber but the scope could still be passed easily to the stomach where the pylorus was intubated. The scope was then passed into the descending duodenum. The duodenal folds were unremarkable. The bulbar mucosa was normal. The antrum was also unremarkable aside from mild mucosal erythema. On retroflexed exam, air was insufflated to distend the fundus. The rugal fold pattern was normal. There was no fundal ulceration or mass. There was a minimal hiatal hernia.
The scope was de-retroflexed and withdrawn to the GE junction. The Z-line was clearly demarcated and the distal most esophageal mucosa was unremarkable. A 12 mm through the scope balloon was passed and fully inflated across the distal third of the esophagus.
It did not achieve occlusion. The balloon was then deflated and withdrawn. A guidewire was passed. The scope was then withdrawn and an optical dilator was passed over the guidewire with the scope inserted into it. The 14, 15, and 16 mm segments were easily passed and there was no resistance and no dilatation. The dilator was withdrawn and a larger optical dilator passed over the guidewire. Again, a 16 mm segment passed but there was minimal resistance but dilatation was achieved with the 17 mm segment and the 18 mm segment. The scope and dilator were withdrawn.
The scope was repassed under direct visualization and mid esophageal biopsies were obtained. The patient tolerated the procedure without immediate complications.
ASSESSMENT:
Esophagitis with an erythematous and trabeculated mucosal pattern and film of exudate suspicious for eosinophilic esophagitis.
Small hiatal hernia with normal distal esophageal mucosa.
Mild elongated stricture of the distal esophagus dilated to 18 mm.
Unremarkable stomach and duodenum.
Vickie Mounce
PREOPERATIVE DIAGNOSIS: Esophagitis with history of stricture and persistent dysphagia.
POSTOPERATIVE DIAGNOSES:
Esophagitis.
Mild elongated esophageal stricture.
PROCEDURE: Esophagogastroduodenoscopy with esophageal biopsies and esophageal dilatation.
OPERATIVE PROCEDURE: Following informed consent, the patient was placed in the left lateral decubitus position and general anesthesia was administered. The scope was then passed under direct visualization through the oropharynx and into the esophagus. The esophagus had a mildly erythematous appearance with a thin layer of whitish exudative material. There was a trabeculated appearance of the mucosa diffusely. In the distal third of the esophagus, there was subtle decrease in the luminal caliber but the scope could still be passed easily to the stomach where the pylorus was intubated. The scope was then passed into the descending duodenum. The duodenal folds were unremarkable. The bulbar mucosa was normal. The antrum was also unremarkable aside from mild mucosal erythema. On retroflexed exam, air was insufflated to distend the fundus. The rugal fold pattern was normal. There was no fundal ulceration or mass. There was a minimal hiatal hernia.
The scope was de-retroflexed and withdrawn to the GE junction. The Z-line was clearly demarcated and the distal most esophageal mucosa was unremarkable. A 12 mm through the scope balloon was passed and fully inflated across the distal third of the esophagus.
It did not achieve occlusion. The balloon was then deflated and withdrawn. A guidewire was passed. The scope was then withdrawn and an optical dilator was passed over the guidewire with the scope inserted into it. The 14, 15, and 16 mm segments were easily passed and there was no resistance and no dilatation. The dilator was withdrawn and a larger optical dilator passed over the guidewire. Again, a 16 mm segment passed but there was minimal resistance but dilatation was achieved with the 17 mm segment and the 18 mm segment. The scope and dilator were withdrawn.
The scope was repassed under direct visualization and mid esophageal biopsies were obtained. The patient tolerated the procedure without immediate complications.
ASSESSMENT:
Esophagitis with an erythematous and trabeculated mucosal pattern and film of exudate suspicious for eosinophilic esophagitis.
Small hiatal hernia with normal distal esophageal mucosa.
Mild elongated stricture of the distal esophagus dilated to 18 mm.
Unremarkable stomach and duodenum.