jojogi
Guest
My gastroenterologist perfomed an EGD that was terminated early and I need to know if I should use a modifier 53 since it looks like the procedures were actually completed. Here is the actual wording on the Endoscopy report -
TECHNIQUE: A BITE BLOCK WAS INSERTED IN THE ORAL CAVITY AFTER OBTAINING
INFORMED CONSENT. THE EGD SCOPE WAS PASSED THROUGH THE OROPHARYNX INTO THE ESOPHAGUS, AND COMPLETE EGD DOWN TO THE SECOND PORTION OF THE DUODENEM, RETROFLEXION IN THE STOMACH.
FINDINGS: THE ESOPHAGUS APPEARED NORMAL. THE GASTROESOPHAGEAL JUNCTION
WAS NORMAL. THERE WAS AN 8 TO 10-MM ULCER ALONG THE LESSER CURVATURE OF
THE STOMACH, IN THE BODY, WITH AN OVERLYING CLOT AND SOME OOZING NOTED, AS
WELL AS A POSSIBLE VISIBLE VESSEL. EPINEPHRINE WAS INJECTED IN FOUR
QUADRANTS, WITH ADEQUATE BLANCHING. A HEATER PROBE WAS APPLIED FOR
ADDITIONAL HEMOSTASIS; HOWEVER, DUE TO DESATURATION, ADEQUATE COAPTIVE
THERAPY COULD NOT BE ENSURED, AND THE SCOPE HAD TO BE WITHDRAWN AND THE
PROCEDURE TERMINATED. NOTE THAT WE HAD ALREADY LOOKED AT THE PROXIMAL
DUODENUM AND THERE WAS NO EVIDENCE OF BLEEDING, AND NO ULCERS NOTED IN THE
PROXIMAL DUODENUM.
IMPRESSION: GASTRIC ULCER WITH A SECONDARY UPPER GASTROINTESTINAL BLEED,
STATUS POST ENDOSCOPIC HEMOSTASIS; THE PROCEDURE TERMINATED EARLY DUE TO
HYPOXEMIA.
Any help would be greatly appreciated
TECHNIQUE: A BITE BLOCK WAS INSERTED IN THE ORAL CAVITY AFTER OBTAINING
INFORMED CONSENT. THE EGD SCOPE WAS PASSED THROUGH THE OROPHARYNX INTO THE ESOPHAGUS, AND COMPLETE EGD DOWN TO THE SECOND PORTION OF THE DUODENEM, RETROFLEXION IN THE STOMACH.
FINDINGS: THE ESOPHAGUS APPEARED NORMAL. THE GASTROESOPHAGEAL JUNCTION
WAS NORMAL. THERE WAS AN 8 TO 10-MM ULCER ALONG THE LESSER CURVATURE OF
THE STOMACH, IN THE BODY, WITH AN OVERLYING CLOT AND SOME OOZING NOTED, AS
WELL AS A POSSIBLE VISIBLE VESSEL. EPINEPHRINE WAS INJECTED IN FOUR
QUADRANTS, WITH ADEQUATE BLANCHING. A HEATER PROBE WAS APPLIED FOR
ADDITIONAL HEMOSTASIS; HOWEVER, DUE TO DESATURATION, ADEQUATE COAPTIVE
THERAPY COULD NOT BE ENSURED, AND THE SCOPE HAD TO BE WITHDRAWN AND THE
PROCEDURE TERMINATED. NOTE THAT WE HAD ALREADY LOOKED AT THE PROXIMAL
DUODENUM AND THERE WAS NO EVIDENCE OF BLEEDING, AND NO ULCERS NOTED IN THE
PROXIMAL DUODENUM.
IMPRESSION: GASTRIC ULCER WITH A SECONDARY UPPER GASTROINTESTINAL BLEED,
STATUS POST ENDOSCOPIC HEMOSTASIS; THE PROCEDURE TERMINATED EARLY DUE TO
HYPOXEMIA.
Any help would be greatly appreciated