955 East Healthcare Boulevard • SOMEWHERE, FL 32811 •
407-555-1597
PATIENT: GILMORE, STEVEN
ACCOUNT/EHR #: GILMST001
DATE: 09/13/22
Diagnosis: Family history of colon
cancer
Procedure: Colonoscopy
Physician: Marion M. March, MD
Anesthesia: Versed 4 mg, Demerol 75 mg
PROCEDURE: Pt is a 59-year-old male
presenting for a colonoscopy. Pt receives educational material and
is informed of the risks. He acknowledges he understands the nature
of the procedure, the risks, and the consequences, and consents to
the procedure.
The patient is placed in the left lateral decubitus position.
The rectal examination reveals normal sphincter tone and no
masses. A colonoscope is introduced into the rectum and advanced to
the distal sigmoid colon. Further advancement is impossible due to
the marked fixation and severe angulation of the rectosigmoid
colon. Procedure is discontinued.
On withdrawal, no masses or polyps are noted, and the mucosa is
normal throughout. Rectal vault is unremarkable. The patient
tolerates the procedure without difficulty.
IMPRESSION: Normal colonoscopy, only to
the distal sigmoid colon
PLAN: Strong recommendation for a barium
enema
Be sure to list the codes, one code per box, in the correct
sequence, from top to bottom, and in the proper row.
Capitalization, punctuation, and spacing can impact whether or not
your answer is correct. Follow coding best practices. Please list
modifiers with the code they relate to as necessary. Include a
hyphen in between the code and the modifier. Example
Procedure: 43846-74 or for Anesthesia: 00797-P2.
Determine the most accurate CPT code(s) and necessary
modifier(s) for the colonoscopy.
The number of spaces provided does not indicate the number of
codes required to accurately report this encounter.
- Gregory Same Day Surgery 955 East Healthcare Boulevard Somewhere Fl 32811 407 555 1597 Patient Gilmore Steven Acc 1 (158.85 KiB) Viewed 122 times