Suzanne Posted Tue 18th of September, 2012 21:36:32 PM
Patient did a consult for constipation. Rectal revealed a small amount of stool. CT scan reviewed by other doctor, revealed significant dilatation of sigmoid. Impression: Colonic distention with some small bowel distention, query ileus.
A rectal tube was introduced from the anus and advanced gently with the passage of large amount of flatus and relieve of symptoms. We will get x-rays of the abdomen done to evaluate decompression of the colon.
What is the best code for the rectal tube. I wonder if that will be included in the E/M code or should I go with
SuperCoder Answered Wed 19th of September, 2012 17:51:40 PM
It will depend on where it was performed. Use 45999 if done in the ASC/Outpatient Hospital and yes it will be included in the E/M if done as an ofice procedure.