through the case study and determine the most accurate procedure
code(s) and modifier(s), if appropriate.
GREGORY SAME DAY SURGERY
955 East Healthcare Boulevard • SOMEWHERE, FL 32811 •
407-555-1597
PATIENT: RISHER, BELVA
ACCOUNT/EHR #: RISHBE001
DATE: 10/03/22
Diagnosis: Fecal incontinence, diarrhea,
constipation
Procedure: Total colonoscopy with hot
biopsy destruction of sessile 3-mm mid-sigmoid colon polyp and
multiple cold biopsies taken randomly throughout the colon
Physician: Marion M. March, MD
Anesthesia: Demerol 50 mg and Versed 3 mg,
both given IV
PROCEDURE: Pt is a 43-year-old female.
Patient was placed into position. Digital examination revealed no
masses. The pediatric variable flexion Olympus colonoscope was
introduced into the rectum and advanced to the cecum. A picture was
taken of the appendiceal orifice and the ileocecal valve.
The scope was then carefully extubated. The mucosa looked
normal. Random biopsies were taken from the ascending colon, the
transverse colon, the descending colon, the sigmoid colon, and the
rectum. There was a 3-mm sessile polyp in the mid-sigmoid colon
that a hot biopsy destroyed.
IMPRESSION: Sigmoid colon polyp destroyed
by hot biopsy
RECOMMENDATIONS: Follow-up in 7 days for
biopsy results.
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.
- Using The Coding Techniques You Have Learned Carefully Read Through The Case Study And Determine The Most Accurate Proc 1 (158.85 KiB) Viewed 94 times