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LOVE2CODE

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PROCEDURE: Esophagogastroduodenoscopy with enteroscopy and biopsy.

INDICATIONS:
1. Anemia.
2. Pancreatic cancer.
3. Abnormal PET scan showing jejunal mass.

INSTRUMENT: Olympus video pediatric colonoscope.

PREMEDICATIONS: Fentanyl 100 mcg IV, Versed 5 mg IV.

INFORMED CONSENT: Informed consent was obtained from the patient prior to
beginning the procedure with the risks, benefits, alternatives, and limitations of
the procedure explained to the patient in detail with the patient deciding to
proceed with the procedure.

DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus
position. Viscous lidocaine was given swish and swallow prior to insertion of the
colonoscope. Mouth piece was inserted into the mouth. The above premedications
were given in incremental doses to achieve moderate conscious sedation. The
pediatric colonoscope was then inserted into the oropharynx and advanced under
direct visualization to the jejunum. The pediatric colonoscope was then withdrawn
from the jejunum examining the entire mucosa from the jejunum all the way back to
the oropharynx and removal of the colonoscope from the patient. The patient
tolerated the procedure well and was transferred to the recovery room in stable
condition.

COMPLICATIONS: None.

FINDINGS:
1. Esophagus was grossly normal.
2. Stomach showed some mild erythema in the antrum.
3. Duodenum showed some whitish patches in the second and third portions of the
duodenum status post cold forceps biopsy. At approximately 135 cm an
irregular mass lesion 4 cm in size and distal to that lesion was a large 6 cm
circumferential irregular mass almost occupying the entire lumen status post
biopsy. The mass was firm to touch and friable.
 
Have you tried code 43235 & 44361? Code 43235 might be a component to code 44361, but I think you can put a modifier in order to differentiate between the services provided. :)
 
LOVE2CODE said:
PROCEDURE: Esophagogastroduodenoscopy with enteroscopy and biopsy.

INDICATIONS:
1. Anemia.
2. Pancreatic cancer.
3. Abnormal PET scan showing jejunal mass.

INSTRUMENT: Olympus video pediatric colonoscope.

PREMEDICATIONS: Fentanyl 100 mcg IV, Versed 5 mg IV.

INFORMED CONSENT: Informed consent was obtained from the patient prior to
beginning the procedure with the risks, benefits, alternatives, and limitations of
the procedure explained to the patient in detail with the patient deciding to
proceed with the procedure.

DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus
position. Viscous lidocaine was given swish and swallow prior to insertion of the
colonoscope. Mouth piece was inserted into the mouth. The above premedications
were given in incremental doses to achieve moderate conscious sedation. The
pediatric colonoscope was then inserted into the oropharynx and advanced under
direct visualization to the jejunum. The pediatric colonoscope was then withdrawn
from the jejunum examining the entire mucosa from the jejunum all the way back to
the oropharynx and removal of the colonoscope from the patient. The patient
tolerated the procedure well and was transferred to the recovery room in stable
condition.

COMPLICATIONS: None.

FINDINGS:
1. Esophagus was grossly normal.
2. Stomach showed some mild erythema in the antrum.
3. Duodenum showed some whitish patches in the second and third portions of the
duodenum status post cold forceps biopsy. At approximately 135 cm an
irregular mass lesion 4 cm in size and distal to that lesion was a large 6 cm
circumferential irregular mass almost occupying the entire lumen status post
biopsy. The mass was firm to touch and friable.
Click to expand...

IMO you should use 44361. 43235 is a base code procedure, as indicated separate procedure.
 
The problem is the actual procedure note does not indicate that a biopsy was performed. The finds state post biopsy but when was that done exactly? I would send the note back for clarification and addendum. Otherwise The only code I see dictated is the 43235.
If the biopsy were dictated then you would bill only the 44361, you cannot bill the without biopsy once you bill the with biopsy, and you should never use the 59 modifier to try to get paid for both.
 
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