jojogi
Guest
I cannot find a code for endorectal ultrasound. Based on this report I came up with the following codes: 45335, 45305 (the scope only went to about 15 cm). Any guidance would be greatly appreciated. Thanks.
INDICATIONS: RECTAL MASS: THIS 52-YEAR-OLD GENTLEMAN IS REFERRED FOR
ENDORECTAL ULTRASOUND AFTER A COLONOSCOPY LAST WEEK SHOWED A MALIGNANT
POLYP AT 25 CM, AND A LARGE TUBULOVILLOUS ADENOMA IN THE RECTUM. I AM NOW
ASKED TO ASSESS FOR INVASION.
THE PROCEDURES, A FLEXIBLE SIGMOIDOSCOPY AND AN ENDORECTAL ULTRASOUND, WERE
EXPLAINED TO THE PATIENT, WITH POTENTIAL RISKS AND COMPLICATIONS INVOLVED.
ALL QUESTIONS WERE ANSWERED. THE PATIENT GAVE INFORMED CONSENT TO THE
PROCEDURES.
TECHNIQUE AND FINDINGS: THE ADULT GASTROSCOPE WAS INSERTED THROUGH THE
RECTUM, AND ADVANCED UNDER INSUFFLATION TO ABOUT 40 CM. THE PREP WAS VERY
GOOD. AROUND 25 TO 30 CM, THE PREVIOUS POLYPECTOMY SITE IS NOTED, AND SPOT
INK INJECTIONS ARE PERFORMED ON SEVERAL LOCATIONS OF THE COLON AROUND THE
POLYPECTOMY SITE FOR SURGICAL MARKING.
ON FURTHER WITHDRAWAL IN THE RECTUM THEN, PRIMARILY SEEN ON RETROFLEX EXAM,
IS A LARGE, 3 TO 4-CM POLYP. THE AIR IS REMOVED AND THE INSTRUMENT
WITHDRAWN.
AFTER REMOVAL OF THE GASTROSCOPE, THE RADIAL ECHOENDOSCOPE IS INSERTED
THROUGH THE RECTUM AND ADVANCED TO ABOUT 15 CM. THE BALLOON IS INSUFFLATED
WITH WATER AND THEN, ON SLOW WITHDRAWAL OF THE INSTRUMENT, THE ULTRASOUND
PROPERTIES ARE NOTED. THE ILIAC VESSELS ARE IDENTIFIED. THE PROSTATE
SHOWS SOME MINOR CALCIFICATIONS, ALTHOUGH IT DOES NOT APPEAR TO BE
ENLARGED. SEMINAL VESICLES ARE ALSO NORMAL.
IN THE MID-RECTUM, A LARGE POLYPOID, MUCOSAL-BASED LESION IS NOTED. THE
MUSCULARIS PROPRIA APPEARS INTACT THROUGHOUT THE ENTIRE RECTUM, AND NO
EVIDENCE OF INVASION IS SEEN. BEHIND THE POLYP, A 9-MM ROUND, OVOID LYMPH
NODE IS SEEN. THE AIR IS REMOVED. AFTER WITHDRAWAL OF THE BALLOON, THE
INSTRUMENT IS REMOVED.
THE PATIENT TOLERATED THE WHOLE PROCEDURE WELL.
IMPRESSION:
1. RECTAL MASS, NO INVASION INTO THE MUSCULAR PROPRIA OR BEYOND IS
NOTED.
2. PREVIOUS POLYPECTOMY SITE AT 25 CM, INJECTED WITH SPOT INK
INDICATIONS: RECTAL MASS: THIS 52-YEAR-OLD GENTLEMAN IS REFERRED FOR
ENDORECTAL ULTRASOUND AFTER A COLONOSCOPY LAST WEEK SHOWED A MALIGNANT
POLYP AT 25 CM, AND A LARGE TUBULOVILLOUS ADENOMA IN THE RECTUM. I AM NOW
ASKED TO ASSESS FOR INVASION.
THE PROCEDURES, A FLEXIBLE SIGMOIDOSCOPY AND AN ENDORECTAL ULTRASOUND, WERE
EXPLAINED TO THE PATIENT, WITH POTENTIAL RISKS AND COMPLICATIONS INVOLVED.
ALL QUESTIONS WERE ANSWERED. THE PATIENT GAVE INFORMED CONSENT TO THE
PROCEDURES.
TECHNIQUE AND FINDINGS: THE ADULT GASTROSCOPE WAS INSERTED THROUGH THE
RECTUM, AND ADVANCED UNDER INSUFFLATION TO ABOUT 40 CM. THE PREP WAS VERY
GOOD. AROUND 25 TO 30 CM, THE PREVIOUS POLYPECTOMY SITE IS NOTED, AND SPOT
INK INJECTIONS ARE PERFORMED ON SEVERAL LOCATIONS OF THE COLON AROUND THE
POLYPECTOMY SITE FOR SURGICAL MARKING.
ON FURTHER WITHDRAWAL IN THE RECTUM THEN, PRIMARILY SEEN ON RETROFLEX EXAM,
IS A LARGE, 3 TO 4-CM POLYP. THE AIR IS REMOVED AND THE INSTRUMENT
WITHDRAWN.
AFTER REMOVAL OF THE GASTROSCOPE, THE RADIAL ECHOENDOSCOPE IS INSERTED
THROUGH THE RECTUM AND ADVANCED TO ABOUT 15 CM. THE BALLOON IS INSUFFLATED
WITH WATER AND THEN, ON SLOW WITHDRAWAL OF THE INSTRUMENT, THE ULTRASOUND
PROPERTIES ARE NOTED. THE ILIAC VESSELS ARE IDENTIFIED. THE PROSTATE
SHOWS SOME MINOR CALCIFICATIONS, ALTHOUGH IT DOES NOT APPEAR TO BE
ENLARGED. SEMINAL VESICLES ARE ALSO NORMAL.
IN THE MID-RECTUM, A LARGE POLYPOID, MUCOSAL-BASED LESION IS NOTED. THE
MUSCULARIS PROPRIA APPEARS INTACT THROUGHOUT THE ENTIRE RECTUM, AND NO
EVIDENCE OF INVASION IS SEEN. BEHIND THE POLYP, A 9-MM ROUND, OVOID LYMPH
NODE IS SEEN. THE AIR IS REMOVED. AFTER WITHDRAWAL OF THE BALLOON, THE
INSTRUMENT IS REMOVED.
THE PATIENT TOLERATED THE WHOLE PROCEDURE WELL.
IMPRESSION:
1. RECTAL MASS, NO INVASION INTO THE MUSCULAR PROPRIA OR BEYOND IS
NOTED.
2. PREVIOUS POLYPECTOMY SITE AT 25 CM, INJECTED WITH SPOT INK