I could use some help cpt and Dx coding on the following op report:
Indication: Fore Early Satiety, Abdominal Pain and history of Cohn's/ Ulcerative Colitis
HPI: This is a patient with a history of ulcerative colitis status post Proctocolectomy and a J-Pouch surgery, now with several weeks of early satiety and abdominal pain. The patient has been on three dose's of Remicade.
Procedure: The patient was sedated by Anesthesia. Her pulse, vitals and oxygenation were monitored. A Colonoscope was inserted into the pouch and passed approximately to 25 to 30 cm. with visualization of the mucosa and then withdrawn.
Findings: Two to three small white ulcerations in the pouch, with random Biopsies taken. The ileum above appeared normal, with random biopsies taken.
Assessment: Likely minimal pouchitis.
Thanks in advance for your help.
Indication: Fore Early Satiety, Abdominal Pain and history of Cohn's/ Ulcerative Colitis
HPI: This is a patient with a history of ulcerative colitis status post Proctocolectomy and a J-Pouch surgery, now with several weeks of early satiety and abdominal pain. The patient has been on three dose's of Remicade.
Procedure: The patient was sedated by Anesthesia. Her pulse, vitals and oxygenation were monitored. A Colonoscope was inserted into the pouch and passed approximately to 25 to 30 cm. with visualization of the mucosa and then withdrawn.
Findings: Two to three small white ulcerations in the pouch, with random Biopsies taken. The ileum above appeared normal, with random biopsies taken.
Assessment: Likely minimal pouchitis.
Thanks in advance for your help.
