CPT CODE HELP

Good morning,
Can someone help me with what CPT code they would use for this procedure, please? Thanks in advance!!!

Procedure: Upper GI endoscopy
Indications: Iron deficiency anemia

Procedure: After obtaining informed consent, the endoscope was
passed under direct vision. Throughout the procedure, the
patient's blood pressure, pulse, and oxygen saturations
were monitored continuously. The Endoscope was introduced
through the mouth, and advanced to the second part of
duodenum. The upper GI endoscopy was accomplished without
difficulty. The patient tolerated the procedure well.

Findings:
Grade I varices were found in the lower third of the esophagus.
Moderate gastric antral vascular ectasia without bleeding was present in
the gastric antrum. Coagulation for bleeding prevention using argon beam
was successful.
The examined duodenum was normal.

Impression: - Grade I esophageal varices.
- Gastric antral vascular ectasia without bleeding.
Treated with argon beam coagulation.
- Normal examined duodenum.
- No specimens collected.

Cindy Wensmann, CPC
Cardiac Surgery/Gastroenterology Coding Specialist II
CentraCare Health
320-229-4916 Ext. 71627
wensmannc@centracare.com

Comments

  • Does someone else have a different reply? There isn't any bleeding at this time so would this truly be a control of hemorrhage? Thanks!

    Cindy Wensmann, CPC
    Cardiac Surgery/Gastroenterology Coding Specialist II
    CentraCare Health
    320-229-4916 Ext. 71627
    wensmannc@centracare.com
  • I would use 43270 as there is no mention of bleeding. And I think bleeding prevention is different than bleeding control. Just my opinion.
    You could always check with the doctor to see if there was bleeding?

    Chris Kraft, CPC
    Digestive Disease Consultants
    1302 Franklin Ave. Suite 4800
    Normal, IL 61761
    309-454-5900
  • I would use the 43270. Not bleeding so just an ablation of the tissue for bleeding prevention.

    Myia Johnson, RHIA
    Business Office Manager
    Lafayette General Endoscopy Center
    1211 Coolidge Blvd Suite 302
    Lafayette, LA 70503
    337-289-8249
    337-289-8246(fax)
    337-289-8245 (direct line)
  • Hi All,
    I have one more I would like to see how others would code. Thanks again!!!

    Procedure: Small bowel enteroscopy
    Indications: Anemia

    Findings:
    The examined esophagus was normal.
    Striped moderately erythematous mucosa without bleeding was found in the
    entire examined stomach.
    There was no evidence of significant pathology in the duodenal bulb and
    in the second part of the duodenum.
    Six angiodysplastic lesions with no bleeding were found in the distal
    duodenum and proximal jejunum. Coagulation for tissue destruction using
    bipolar probe was successful.

    Impression: - Erythematous mucosa in the stomach.
    - Six non-bleeding angiodysplastic lesions in the
    duodenum and jejunum. Treated with bipolar cautery.
    - No specimens collected.

    Cindy Wensmann, CPC
    Cardiac Surgery/Gastroenterology Coding Specialist II
    CentraCare Health
    320-229-4916 Ext. 71627
    wensmannc@centracare.com
  • 44365

    Myia Johnson, RHIA
    Business Office Manager
    Lafayette General Endoscopy Center
    1211 Coolidge Blvd Suite 302
    Lafayette, LA 70503
    337-289-8249
    337-289-8246(fax)
    337-289-8245 (direct line)
  • 44369

    Chris Kraft, CPC
    Digestive Disease Consultants
    1302 Franklin Ave. Suite 4800
    Normal, IL 61761
    309-454-5900
  • Oops, 44365. Sorry about that.

    Chris Kraft
    Digestive Disease Consultants
    1302 Franklin Ave. Suite 4800
    Normal, IL 61761
    309-454-5900
  • What CPT code would you suggest?

    (Non-essential info has been omitted)

    Procedure: Colonoscopy
    Indications for Exam: Anemia, Multiple AVMs in the cecum & ascending colon
    Extent of Exam: Terminal ileum
    Procedure Technique:
    Physical exam performed...
    Consent obtained.....
    Risks explained.....
    Timeout performed.....
    Connected to monitoring devices.....
    ....colonoscope was passed & advanced to the cecum, the position of which was verified by the finding of cecal base landmarks & the ileo-cecal valve. The ileo-cecal valve was intubated, & the terminal ileum is inspected for a short distance, appearing normal. The colon was inspected on withdrawal. The bowel prep was good. Endoscopic findings are otherwise described below. Examination did not include retroflexion in the rectum.
    FINDINGS

    1. Multiple nonbleeding AVMs, 2-7mm, were seen in the cecum (8) & two in the ascending colon. I was not able to use the APC machine due to unforeseen technical problem. I elected to treat with clips and gold probe on a very low setting (effect 2 and Watts 20.) Twelve clips were placed strategically to cut the blood supply from the feeding vessels to the large AVMs and then were all treated with gold probe cautiously with minimal burning and minimal pressure used. No active bleeding was seen. The colon was then decompressed and the scope was withdrawn.

    2. Bowel prep was good.
    RECOMMENDATIONS:
    Etc, etc, etc.

    I appreciate your help!


    Laurie Johnson
    Laurie Johnson, CCS, COC
    Certified Coder
    Hannibal Regional Healthcare System
    573-248-5421 (O)
    Laurie.johnson@hrhonline.org
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