What are the service codes for this? LOCATION: Outpatient, Hospital PATIENT: Jat

Question

What are the service codes for this? LOCATION: Outpatient, Hospital PATIENT: Jatin Al-Assad SURGEON: Larry Friendly, MD SCOPE USED: Pentax video colonoscope MEDICATIONS GIVEN: Fentanyl 75 mg (microgram) and Versed 3 mg (milligram) IV (intravenous) prior to the procedure PREOPERATIVE DIAGNOSIS: Polyp on sigmoidoscopy POSTOPERATIVE DIAGNOSIS: Colon polyps PROCEDURE PERFORMED: Colonoscopy with removal of polyps INDICATION: The patient is a 48-year-old male who presented for screening sigmoidoscopy on January 15. He was found to have several adenomatous polyps in the sigmoid colon and rectum. This procedure is being done to remove those polyps and any other polyps in the more proximal colon. FINDINGS: About five polyps were seen, three pedunculated and two sessile. These were snared. The remainder of the colon and rectum were normal. DESCRIPTION OF TECHNIQUE: After informed consent was obtained, the patient was prepared for colonoscopy. He was placed in the left lateral decubitus position. A digital rectal examination was performed and was unremarkable. The lubricated Pentax video colonoscope was then guided digitally into the rectum and advanced to the cecum. The scope was withdrawn and the mucosa inspected. The cecum, ascending colon, transverse colon, and descending colon were normal. Through the sigmoid colon and rectum, five polyps were seen. The largest measured about 1 cm (centimeter) in diameter. Three were pedunculated. These were snared. Two others were smaller and sessile. The distal rectum was normal. The scope was withdrawn. The patient tolerated the procedure well and was discharged ambulatory with a driver. RECOMMENDATIONS: Follow-up colonoscopy in 2 years due to the relatively large number of polyps seen on this examination in a relatively young man. Pathology Report Later Indicated: See Report 7-8B. SERVICE CODE(S): __________________________________

Explanation / Answer

Physican is perfomed Surgical Colonoscopy with polyps removeal at Rectam and Sigmoid colon by snare techinque as per AMA guidelines the cpt code is correct service Code

Service Code is : Current Procedure Terminology (45385)

colonoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique

Dignosis Code

ICD 10 CM - K63.5

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