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Procedure: Pouchoscopy

Eleen Posted Tue 13th of September, 2016 15:01:21 PM
Findings: The perianal and digital rectal examinations were normal. The neo-terminal ileum appeared normal. Biopsies were taken with a cold forceps for histology. There was a rectal cuff beginning at at 1 cm from the anal verge, characterized by edema and erythema. Biopsies were taken with a cold forceps for histology. The j-pouch contained an area of normal mucosa vascular pattern. Biopsies were taken with a cold forceps for histology. Is the code 44389?
SuperCoder Answered Wed 14th of September, 2016 02:10:54 AM

Hi,

The informaton provided by you is limited. Supercoder can suggest the below points for appropriate coding,

  • When your gastroenterologist performs an endoscopic procedure through a stomal opening, your reporting primarily depends on the previous surgical procedure when the stoma was created. If the initial procedure was a colectomy with an ileostomy (the end of the ileum is connected to the stoma), you will have to report an endoscopy through stoma using ileoscopy through the stoma codes (44380 -- 44382, Ileoscopy, through stoma...).
  • If a partial colectomy and a colostomy (the colon is connected to the stoma) were performed earlier, then an endoscopic procedure through stoma should be reported using colonoscopy through stoma codes (44388 -- 44397, Colonoscopy through stoma...).
  • If the earlier procedure involved the creation of an ileal pouch before it connects to the stomal opening, an endoscopic procedure through stoma should be reported using 44385 -- 44386 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch...).

If  in your case its endoscopy through J pouch? Then the CPT code will be 44386, Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple

Thanks

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