Ravikirann
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Dear Folks,
Guide me what cpt codes i can select from this OP notes.
INDICATIONS: The patient is a 69-year-old male, who presents today with epigastric discomfort. It is worst by eating meals. It has been present for the last several months. He presents today for EGD and colonoscopy exam.
FINDINGS: At the time of the procedure, the patient was noted to have esophagitis that was mild in severity. There was an esophageal stricture noted. He had mild gastritis and he had moderate sliding hiatal hernia. There were no signs of Barrett?s esophagus. The duodenum appeared normal. On colonoscopy exam, he was noted to have a 40 cm pedunculated polyp and a flat polyp that was removed with cold biopsy forceps and pedunculated polyp was removed with a cautery and snare. Cecum polyp was removed with a cautery and snare.
TECHNIQUE: After informed consent was obtained including the risk of bleeding, infection, perforation, missed lesions, and plans for MAC anesthetic, the patient was brought to the endoscopy suite, placed in the left lateral decubitus position. IV access was obtained, colonoscopy was attached, and the MAC anesthetic was begun. Pharynx was anesthestized with Hurricaine spray and a bi-pack was placed and then gastroscope was easily introduced into the retropharynx and guided down the esophagus, which was mildly presbyoptic. Esophageal stricture was encountered. It was dilated with 20 mm balloon. The GE junction was fairly normal, which is some very mild esophagitis. The stomach was intubated and it was cleared off, which is a small amount of bile and the gastric leak. There was mild gastritis without any frank ulcerations. Now, J-maneuver was performed showing a hiatal hernia, but the remainder of the cardia and fundus appeared normal. The pylorus opening was inspected and found to be normal and the first and second portion of the duodenum was intubated and appeared to be normal. Biopsies were then taken off the antrum for H. pylori as well as the GE junction from mild esophagitis. No obvious Barrett?s esophagus was seen. There was clear hiatal hernia, sliding type. Next, the area was deflated into the stomach and the scope was withdrawn, inspecting the esophagus, and further withdrawing of the scope and no other gross abnormalities were seen.
Next, a digital rectal exam was performed, which revealed some hemorrhage, but no masses. The colonoscope was then introduced into the cecum and guided to the cecum, where the appendiceal orifice was identified and the ileocecal valve. In the cecum, there was a pedunculated polyp taken off with a cautery and snare and suctioned to the scope. The remainder of the cecum, right colon, and transverse colon appeared normal. The left colon appeared normal. In the sigmoid colon at approximately 40-cm, again a pedunculated polyp was identified taken off of the cautery and snare. Next, in this area, there was a small polyp that was more flat rather. Even a small submucosal lipoma as the mucosa was pretty normal or it could be just a hyperplastic polyp, this was taken off with cold biopsy forceps. There was some diverticulosis in the area. The remainder of the sigmoid and rectum appeared normal. A J-maneuver was performed showing a normal internal opening. The colonoscope was withdrawn.
The patient tolerated the procedure well and transferred to the recovery area in stable condition.
Thanks
Guide me what cpt codes i can select from this OP notes.
INDICATIONS: The patient is a 69-year-old male, who presents today with epigastric discomfort. It is worst by eating meals. It has been present for the last several months. He presents today for EGD and colonoscopy exam.
FINDINGS: At the time of the procedure, the patient was noted to have esophagitis that was mild in severity. There was an esophageal stricture noted. He had mild gastritis and he had moderate sliding hiatal hernia. There were no signs of Barrett?s esophagus. The duodenum appeared normal. On colonoscopy exam, he was noted to have a 40 cm pedunculated polyp and a flat polyp that was removed with cold biopsy forceps and pedunculated polyp was removed with a cautery and snare. Cecum polyp was removed with a cautery and snare.
TECHNIQUE: After informed consent was obtained including the risk of bleeding, infection, perforation, missed lesions, and plans for MAC anesthetic, the patient was brought to the endoscopy suite, placed in the left lateral decubitus position. IV access was obtained, colonoscopy was attached, and the MAC anesthetic was begun. Pharynx was anesthestized with Hurricaine spray and a bi-pack was placed and then gastroscope was easily introduced into the retropharynx and guided down the esophagus, which was mildly presbyoptic. Esophageal stricture was encountered. It was dilated with 20 mm balloon. The GE junction was fairly normal, which is some very mild esophagitis. The stomach was intubated and it was cleared off, which is a small amount of bile and the gastric leak. There was mild gastritis without any frank ulcerations. Now, J-maneuver was performed showing a hiatal hernia, but the remainder of the cardia and fundus appeared normal. The pylorus opening was inspected and found to be normal and the first and second portion of the duodenum was intubated and appeared to be normal. Biopsies were then taken off the antrum for H. pylori as well as the GE junction from mild esophagitis. No obvious Barrett?s esophagus was seen. There was clear hiatal hernia, sliding type. Next, the area was deflated into the stomach and the scope was withdrawn, inspecting the esophagus, and further withdrawing of the scope and no other gross abnormalities were seen.
Next, a digital rectal exam was performed, which revealed some hemorrhage, but no masses. The colonoscope was then introduced into the cecum and guided to the cecum, where the appendiceal orifice was identified and the ileocecal valve. In the cecum, there was a pedunculated polyp taken off with a cautery and snare and suctioned to the scope. The remainder of the cecum, right colon, and transverse colon appeared normal. The left colon appeared normal. In the sigmoid colon at approximately 40-cm, again a pedunculated polyp was identified taken off of the cautery and snare. Next, in this area, there was a small polyp that was more flat rather. Even a small submucosal lipoma as the mucosa was pretty normal or it could be just a hyperplastic polyp, this was taken off with cold biopsy forceps. There was some diverticulosis in the area. The remainder of the sigmoid and rectum appeared normal. A J-maneuver was performed showing a normal internal opening. The colonoscope was withdrawn.
The patient tolerated the procedure well and transferred to the recovery area in stable condition.
Thanks
