AR2728
Expert
I am a bit confused by the following op note. I'm not sure that I can bill 43255 for the following documentation. Advice would be appreciated!!
The patient did have evidence of clot in the proximal stomach. This was grasped with the hot biopsy forceps, pulled well away from the wall and was cauterized with Bovie
cautery destroying the lesion and removing the tissue to send it for histology. It was not
certain that this was not NG trauma but there was a fresh clot and an underlying vascular
malformation could not be ruled out. The clot was adherent and therefore the clot and
surrounding tissue were grasped, pulled well away from the wall and with two firings of
the hot biopsy forceps, the tissue was removed and the underlying bleeding destroyed and
controlled. Visualization revealed no further bleeding or ooze. Clot was removed in this
fashion. A biopsy was also obtained with hot biopsy forceps from the antrum to rule out
helicobacter. Remainder of exam was as per above. Excess air and fluid were aspirated
and the scope was removed. The patient tolerated the procedure well. There were no
biopsies obtained from the esophagus to prevent stirring up bleeding. It was not certain
whether the patient had a small vascular malformation on the proximal esophagus which
may have bled. The area of the clot was pulled well away from the wall and was
destroyed with tissue removed and sent to histology to rule this out. If there was a
vascular malformation, this was adequately destroyed. Biopsy was also obtained from
the antrum but the patient did not appear to have any large ulcers or erosive gastritis. The
only inflammation was in the area of the cardia. It could not be ruled out absolutely that
this may not have come from the patient's NG tube but the NG drainage had been clear
and there was clot in this region. Unless this was trauma from removal of the NG tube
which would appear to be unlikely with a single spot, a vascular lesion or Dieulafoy
lesion could not be ruled out. It also could not be ruled out that this was NG trauma and
that no upper GI source is present. Exam was complicated by significant breathing and
respiratory excursion as well as spasticity but eventually adequate exam was obtained.
The patient did have evidence of clot in the proximal stomach. This was grasped with the hot biopsy forceps, pulled well away from the wall and was cauterized with Bovie
cautery destroying the lesion and removing the tissue to send it for histology. It was not
certain that this was not NG trauma but there was a fresh clot and an underlying vascular
malformation could not be ruled out. The clot was adherent and therefore the clot and
surrounding tissue were grasped, pulled well away from the wall and with two firings of
the hot biopsy forceps, the tissue was removed and the underlying bleeding destroyed and
controlled. Visualization revealed no further bleeding or ooze. Clot was removed in this
fashion. A biopsy was also obtained with hot biopsy forceps from the antrum to rule out
helicobacter. Remainder of exam was as per above. Excess air and fluid were aspirated
and the scope was removed. The patient tolerated the procedure well. There were no
biopsies obtained from the esophagus to prevent stirring up bleeding. It was not certain
whether the patient had a small vascular malformation on the proximal esophagus which
may have bled. The area of the clot was pulled well away from the wall and was
destroyed with tissue removed and sent to histology to rule this out. If there was a
vascular malformation, this was adequately destroyed. Biopsy was also obtained from
the antrum but the patient did not appear to have any large ulcers or erosive gastritis. The
only inflammation was in the area of the cardia. It could not be ruled out absolutely that
this may not have come from the patient's NG tube but the NG drainage had been clear
and there was clot in this region. Unless this was trauma from removal of the NG tube
which would appear to be unlikely with a single spot, a vascular lesion or Dieulafoy
lesion could not be ruled out. It also could not be ruled out that this was NG trauma and
that no upper GI source is present. Exam was complicated by significant breathing and
respiratory excursion as well as spasticity but eventually adequate exam was obtained.