rearch 3 code cpt A 81 year

rearch 3 code cpt A 81 year old female presents for an elective EGD-Colonoscopy. ASA Class: P2 EGD Indications: Dysphagia: 787.21 – R13.11 Colonoscopy Indications: Colon cancer screening (low/average risk): V76.51 – Z12.11 Administered Medications: Fentanyl 100 mcg IV Lidocaine jelly 2 % topical Versed 6 mg IV Sedation Time: Intra-service time of 50 minutes (10:05 AM – 10:55 AM). Colonoscopy Colonoscopy Procedure: This is a average risk patient undergoing screening colonoscopy. Prior colonoscopy timeframe: five to ten years. The quality of preparation was excellent. Patient was placed in left lateral decubitus position. The colonoscope was introduced through rectum and advanced under direct visualization until cecum reached. The appendiceal orifice was seen. The colonoscope was retroflexed within the rectum. Careful visualization was performed as the instrument was withdrawn. Patient tolerance to the procedure was excellent. The procedure was difficult. Digital exam was normal. Estimated Blood Loss: Minimal Colonoscopy Limitations/Complications: Colonoscopy Findings: Excavated lesions Multiple diverticula were seen in the sigmoid colon. Diverticulosis appeared to be severe. Flat lesions A few medium localized angioectasias were seen in the cecum. Mucosa Normal mucosa was noted in the whole colon. Protruding lesions A single flat 4 mm polyp of benign appearance was found in the descending colon. A polypectomy was performed using a cold snare. The polyp was completely removed. Hypertrophied anal papillae was noted. EGD EGD Procedure: Patient was placed in a left lateral decubitus position. The endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. The Z-line was noted at 38 centimeters. Site of diaphragmatic hiatus noted at 38 centimeters. Patient tolerance to the procedure was good. The procedure was not difficult. Estimated Blood Loss: Minimal EGD Limitations/Complications: There were no apparent limitations or complications EGD Findings: A single diverticulum with a large opening was seen in the cricopharyngeus. This finding is anatomically consistent with a Zenker’s diverticulum approximately 2cm in length. Lumen A Schatzki’s ring was found in the gastroesophageal junction. A 18 mm balloon was introduced for dilation and the diameter was progressively increased to 20 mm successfully. No tears seen post-dilation. Mucosa Grade B esophagitis with no bleeding was seen starting at 30 cm from the incisors in the gastroesophageal junction, compatible with esophagitis. Scattered faint 3-7mm linear erosions in distal esophagus. Multiple cold forceps biopsies were performed for histology. Additional esophagus findings The esophagus was otherwise normal. Stomach Mucosa Diffuse atrophy of gastric folds of the mucosa was noted in the stomach body. Multiple cold forceps biopsies were performed for histology. Additional stomach findings Hill Grade 2 GEJ. The stomach was otherwise normal. EGD Impressions: Grade B esophagitis in the gastroesophageal junction compatible with esophagitis. (Biopsy). Ring in the gastroesophageal junction. (Dilation). Atrophy of gastric folds in the stomach body. (Biopsy). Normal mucosa in the whole examined duodenum. The stomach was otherwise normal. The esophagus was otherwise normal.

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