Wiki Help CPT coding this report please.

chewri

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A 52 year old female presents for a Colonoscopy

Indications Abnormal CT

Consent: After obtaining history and performing the physical examination, the procedure, indications, potential complications such as bleeding, perforation, infection, adverse medication reaction, and alternatives were explained to the patient. Patient appeared to understand the benefits and risks of this procedure. Informed consent was obtained from the patient after providing opportunity for questions.

Preparation: ECG pulse, blood pressure, and oxygen saturation monitored.

Anesthesia: MAC [MAC]

Procedure: After placing the patient in the left lateral position, the colonoscope was gently inserted into the anus and under direct visualization advanced to the terminal ileum, which was identified by visualization of cecum and appendiceal orifice. The mucosa and anatomy of the colon were carefully examined. The procedure was performed without difficulty, the quality of preparation was excellent. The patient tolerated the procedure well and there were no complications. After completion of the examination, the patient was transferred to the recovery room.

Insertion Point: Anus

Space Reached: Terminal Ileum

Instrument: Colon #138 - Serial # A110138

Findings
Anal Canal Normal.

Sigmoid Colon Normal.
Scope inserted through ostomy Biopsies taken.

Descending Colon Normal.
Biopsies taken.

Splenic Flexure Normal.

Transverse Colon Normal.
Biopsies taken.

Hepatic Flexure Normal.

Ascending Colon Normal.
Biopsies taken.

Cecum Normal.
Biopsies taken of cecum and terminal ileum.

Complications: No.

Impressions Post-surgical changes, otherwise normal

Recommendations: ROC in 2-3 weeks
 
This note is not great.
I think you need to query the physician since it says in the body of the note that they inserted the scope into the anus and readily took it to the terminal ileum but in the rest of the note said they also inserted into ostomy and biopsied.
Without that part it would be
45380
793.4 and then I assume a code of an artificial opening or past removal of colon parts but that is not mentioned in the note.
There is a code of biopsy through an ostomy so query the doctor. The note should have at least mentioned that patient had ostomy or partial removal of colon in past.
 
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