TWO DIAGNOSIS CODES PLEASE!!! Code this report as if you work for the physician
ID: 243732 • Letter: T
Question
TWO DIAGNOSIS CODES PLEASE!!!
Code this report as if you work for the physician
Coding Hint: There are two diagnosis codes and one HCPCS code associated with this report.
This is a 67-year-old female referred for screening colonoscopy. Does not really have any obvious complaints. No constipation, diarrhea. No family history of colon cancer.
PAST MEDICAL HISTORY: Significant for hypertension.
PROCEDURE: Colonoscopy.
INDICATIONS: Age related screening
ANESTHESIA: Fentanyl 100 mcg IV and Versed 2 mg IV.
INSTRUMENT: Olympus video colonoscope.
PREPARATION: Adequate.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the endoscopy (?) and placed in the left lateral decubitus position. The above IV sedatives were given until adequate anesthesia was achieved. After doing a rectal exam, which was unrevealing, the Olympus video colonoscope was placed in the patients rectum and proceeded slowly and carefully under direct vision to the cecum. The cecum was identified using landmarks. The colonic mucosa appeared normal. Colonoscope was withdrawn. Colonoscope was withdrawn. Transverse colonic mucosa appeared normal. The colonoscope was retreflected and withdrawn. The patient tolerated the procedure well. There were no complications.
ASSESSMENT/PLAN: Normal screening colonoscopy. Follow up in 5 yrs.
Explanation / Answer
Normal screening colonoscopy code 45378
G0105-74 Colorectal cancer screening;colonoscopy on individuals not meeting criteria for high risk individual
append modifier -74 to indicate a discontinued outpatient procedure after anesthesia administration.
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