kwashburn13
New
After reading the following report, I'm tempted to code and charge 43255 x 2 with a modifier. What would you do?
"Stomach: The gastric mucosa was closely inspected throughout including retroflexion. The gastric mucosa was notable for old blood clots in the fundus of the stomach which was suctioned away. A diminutive clean-based ulcer was noted at the pylorus with surrounding erythema. This ulcer was treated with argon plasma coagulation. The patient has had a pyloroplasty. There were Brunner's glands noted in the bulb but there was no ulceration.
Duodenum: The duodenal mucosa was notable for a >4 cm duodenal ulcer in the bulb with irregular margins. Ulceration was mostly clean-based. There was one suture site identified which was within the ulcer. There was a visible vessel in direct proximity to this suture site. This vessel was treated epinephrine injection and argon plasma coagulation. A second visible vessel was noted just distal to the suture site. This second visible vessel was also treated with epinephrine injection and argon plasma coagulation. Duodenal mucosa was otherwise normal except for old blood clots. "
"Stomach: The gastric mucosa was closely inspected throughout including retroflexion. The gastric mucosa was notable for old blood clots in the fundus of the stomach which was suctioned away. A diminutive clean-based ulcer was noted at the pylorus with surrounding erythema. This ulcer was treated with argon plasma coagulation. The patient has had a pyloroplasty. There were Brunner's glands noted in the bulb but there was no ulceration.
Duodenum: The duodenal mucosa was notable for a >4 cm duodenal ulcer in the bulb with irregular margins. Ulceration was mostly clean-based. There was one suture site identified which was within the ulcer. There was a visible vessel in direct proximity to this suture site. This vessel was treated epinephrine injection and argon plasma coagulation. A second visible vessel was noted just distal to the suture site. This second visible vessel was also treated with epinephrine injection and argon plasma coagulation. Duodenal mucosa was otherwise normal except for old blood clots. "