Wiki Op Report.

[lindafay1123]

help if procedure coding
The Olympus CF1T100L video colonoscope was gently inserted into the patient?s rectum and advanced slowly under direct visualization to the cecum which was identified via the usual landmarks and via transillumination. Upon reaching the cecum the terminal ileum was also intubated and examined. Subsequently, the colonoscope was gradually withdrawn allowing careful examination of the distal terminal ileum and the colonic ileum. A turn around examination was also performed in the rectum. There appeared to be aphthous ulcerations in the transverse colon. Multiple biopsies were taken of the ulcerated areas. There was also a 2 cm extremely sessile polyp on a fold at 60 cm (transverse colon) removed via a snare. There were a few diverticula in the sigmoid colon. No other abnormalities were found. Prior to withdrawal of the colonoscope, air was removed from the patient?s rectum. Complications ? none. The patient tolerated the procedure well.
I believe the procedure code is 45385.
Also is the pathologic microscopic dx what I code

 

[OCD_coder]

You are correct for the CPT code 45385.

Diagnosis:
1. Wait for the path report and use those diagnosis as your primary.
2. If you can't wait for the path report code the apthous ulcers and polyps (unspecified) as findings from the colonoscopy.