ksb0211
Guest
I know how I would code this if only one of our surgeons performed this. My question is how to bill since there were 2 different surgeons from our group involved. Here is the op report. It was dictated by Dr. "Jekyll."
PROCEDURE/OPERATION
Percutaneous endoscopic gastrostomy tube insertion.
ENDOSCOPIST
Dr. "Jekyll"
SURGEON
Dr. "Hyde"
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room and after induction of adequate anesthesia, the patient was turned to the left lateral position.
The Olympus fiberoptic video upper gastrointestinal endoscope was introduced by Dr. "Jekyll" through the pharynx into the esophagus. The esophagus was basically normal to the level of the gastroesophageal junction which was at 38 cm from the incisors. No significant ulcerations appreciated. The stomach had some minimal amount of food particles. No gastritis was appreciated. The scope was retroflexed. No hiatal hernia was noted, no significant ulceration. The body of the stomach, cardia and fundus were unremarkable. The antrum was within normal limits. The duodenum was intubated.
Following this, the light was visualized on the anterior abdominal wall. Dr. "Hyde" prepped the abdominal wall. The skin was anesthetized with a solution of 1% Xylocaine. The introducer needle was passed through the skin directly into the stomach. The wire was grasped with a snare and then brought retrograde through the esophagus, and through the mouth. The PEG tube was attached, it was then brought back through the mouth, the esophagus, and to lie appropriately in the stomach. The endoscope was reintroduced. The lie of the bolster was appropriate. The bolster was secured. Dry sterile dressing was applied. The patient tolerated the procedure.
Thanks.
PROCEDURE/OPERATION
Percutaneous endoscopic gastrostomy tube insertion.
ENDOSCOPIST
Dr. "Jekyll"
SURGEON
Dr. "Hyde"
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room and after induction of adequate anesthesia, the patient was turned to the left lateral position.
The Olympus fiberoptic video upper gastrointestinal endoscope was introduced by Dr. "Jekyll" through the pharynx into the esophagus. The esophagus was basically normal to the level of the gastroesophageal junction which was at 38 cm from the incisors. No significant ulcerations appreciated. The stomach had some minimal amount of food particles. No gastritis was appreciated. The scope was retroflexed. No hiatal hernia was noted, no significant ulceration. The body of the stomach, cardia and fundus were unremarkable. The antrum was within normal limits. The duodenum was intubated.
Following this, the light was visualized on the anterior abdominal wall. Dr. "Hyde" prepped the abdominal wall. The skin was anesthetized with a solution of 1% Xylocaine. The introducer needle was passed through the skin directly into the stomach. The wire was grasped with a snare and then brought retrograde through the esophagus, and through the mouth. The PEG tube was attached, it was then brought back through the mouth, the esophagus, and to lie appropriately in the stomach. The endoscope was reintroduced. The lie of the bolster was appropriate. The bolster was secured. Dry sterile dressing was applied. The patient tolerated the procedure.
Thanks.