Jenannurb
Contributor
** good morning all
I am coding this procedure done by my physician and I am wondering if I am missing anything by coding it as a 43242.
Input is appreciated.
have a great day!
""EGD/EUS/FNA-Core biopsies
Indication for procedure:*
This is a male patient who presents for EGD/EUS to evaluate pancreas head fullness/liver hilar mass.
Informed consent:* The risks benefits and alternatives to the procedure were explained to the patient who provided informed consent.* Risks discussed included infection, bleeding, perforation, pancreatitis, death, and risks of sedation.
Sedation:* Anesthesiology service sedated patient with monitored anesthesia, see anesthesia notes for details.
Description:* Following sedation a Pentax 3870 UTK curvilinear endosonoscope was inserted though a bite block and passed under direct visualization to the second portion duodenum.* The scope was then extracted examining all four walls of the mucosa.* The scope was retroflexed to examine the incisura, fundus and cardia of the stomach.
Complications:* The patient tolerated all aspects of the procedure well.* There were no immediate complications.
Estimated blood loss: None.
Endoscopic findings:*
The endoscopic findings are normal esophagus, stomach and duodenum including ampullary area
Sonographic findings:
Mediastinum: Normal appearing subcarinal and 4L area lymph nodes. No Masses.
Celiac Axis Area:* Celiac artery and superior mesenteric artery take off from the aorta are examined and are normal in appearance.* There is malignant appearing celiac lymphadenopathy to 11 mm and multiple enlarged perigastric nodes
Lymphatics otherwise: massively enlarged periduodenal and liver hilar nodes to over 4.7 cm. Core biopsies peformed and material sent for flow cytometry.
Left Adrenal gland:* Examined and normal in appearance and there are no masses or lesions.
Pancreas:* The head, body, tail, and uncinate process of the pancreas are carefully examined.* The pancreatic parenchyma is grossly normal in appearance.* There are no focal masses or lesions.* The main pancreatic duct is traced from the level of the ampulla through the head and body of the pancreas and is normal in size and contour.
Liver:* The left lobe of the liver is carefully examined.* The hepatic parenchyma has appearance of multiple small lesions. There is abdominal ascites.
Biliary Tree:* The common bile duct is traced from the level of the ampulla to the hilum. It is dilated above level of nodes c/w at least partial biliary obstruction. Gallbladder is visualized and has a thickened wall and edema and sludge.
The exam was otherwise normal.
Impression:
Malignant appearing portal, liver hilar, periduodenal lymph nodes s/p fna/core biopsies for cytology and flow cytometry
Multiple hepatic lesions c/w metastatic disease as above
Malignant appearing celiac nodes
Nodes adjacent to pancreas but appeared separate from it and no obvious pancreas mass seen.
At least partial biliary obstruction from liver hilar nodes.
Otherwise normal EGD and EUS.""
I am coding this procedure done by my physician and I am wondering if I am missing anything by coding it as a 43242.
Input is appreciated.
have a great day!
""EGD/EUS/FNA-Core biopsies
Indication for procedure:*
This is a male patient who presents for EGD/EUS to evaluate pancreas head fullness/liver hilar mass.
Informed consent:* The risks benefits and alternatives to the procedure were explained to the patient who provided informed consent.* Risks discussed included infection, bleeding, perforation, pancreatitis, death, and risks of sedation.
Sedation:* Anesthesiology service sedated patient with monitored anesthesia, see anesthesia notes for details.
Description:* Following sedation a Pentax 3870 UTK curvilinear endosonoscope was inserted though a bite block and passed under direct visualization to the second portion duodenum.* The scope was then extracted examining all four walls of the mucosa.* The scope was retroflexed to examine the incisura, fundus and cardia of the stomach.
Complications:* The patient tolerated all aspects of the procedure well.* There were no immediate complications.
Estimated blood loss: None.
Endoscopic findings:*
The endoscopic findings are normal esophagus, stomach and duodenum including ampullary area
Sonographic findings:
Mediastinum: Normal appearing subcarinal and 4L area lymph nodes. No Masses.
Celiac Axis Area:* Celiac artery and superior mesenteric artery take off from the aorta are examined and are normal in appearance.* There is malignant appearing celiac lymphadenopathy to 11 mm and multiple enlarged perigastric nodes
Lymphatics otherwise: massively enlarged periduodenal and liver hilar nodes to over 4.7 cm. Core biopsies peformed and material sent for flow cytometry.
Left Adrenal gland:* Examined and normal in appearance and there are no masses or lesions.
Pancreas:* The head, body, tail, and uncinate process of the pancreas are carefully examined.* The pancreatic parenchyma is grossly normal in appearance.* There are no focal masses or lesions.* The main pancreatic duct is traced from the level of the ampulla through the head and body of the pancreas and is normal in size and contour.
Liver:* The left lobe of the liver is carefully examined.* The hepatic parenchyma has appearance of multiple small lesions. There is abdominal ascites.
Biliary Tree:* The common bile duct is traced from the level of the ampulla to the hilum. It is dilated above level of nodes c/w at least partial biliary obstruction. Gallbladder is visualized and has a thickened wall and edema and sludge.
The exam was otherwise normal.
Impression:
Malignant appearing portal, liver hilar, periduodenal lymph nodes s/p fna/core biopsies for cytology and flow cytometry
Multiple hepatic lesions c/w metastatic disease as above
Malignant appearing celiac nodes
Nodes adjacent to pancreas but appeared separate from it and no obvious pancreas mass seen.
At least partial biliary obstruction from liver hilar nodes.
Otherwise normal EGD and EUS.""