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repost: DICTATION REVIEW REQUEST (please ignore the other) - need some help

Melanie Posted Mon 21st of June, 2010 18:55:47 PM

CPT code the physician selected was 43239
Post-Diagnosis is Ulcer at the anastomotic site (upper GI)

Im not really sure what the appropriate diag code would be for this type of ulcer - almost slim pickin's.....perhaps someone could assist? Im still searching so please dont think we are just passing this off... Thank you for any help you can offer.

_________________________________________________________________

DATE OF SURGERY: 06/12/2010

PREOPERATIVE DIAGNOSIS: Melena

POSTOPERATIVE DIAGNOSIS: Ulcer, anastomotic

OPERATION: Esophagogastroduodenoscopy, biopsy.

ANESTHESIA: MAC.

INDICATIONS: The procedure was reviewed with the patient, including the risks
and alternatives. This is a patient who had a Whipple procedure several years
ago for IPMT. He had a subsequent surgical procedure for pancreatic stenosis.
He presented with 3 days of near black stools and drop in his hematocrit. He
does not use NSAIDs.

PROCEDURE: After the patient was sedated, the video endoscope was inserted
into the esophagus and into the stomach. The Billroth II anatomy was
identified. The afferent limb and efferent limb were both entered. Just beyond
the margin on the efferent side behind the fold was an oval ulceration. There
was a faint dark spot that was flat, but no visible vessel or active bleeding.
The area was aggressively irrigated with no bleeding. I did biopsy near the
region to rule out more significant pathology, but this looked very benign.
The gastric remnant was normal. The Z-line was at 40 cm from the incisors.
There was no evidence of Barrett's esophagus or any other esophageal
abnormalities. The patient tolerated the procedure well.

IMPRESSION: Marginal ulceration in a patient status post Whipple procedure. We
will add Carafate chronically to his regimen of PPI.

SuperCoder Answered Tue 22nd of June, 2010 06:52:40 AM

I would suggest 534.90 (since the patient has undergone a Billroth II).

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