Determine the most accurate cpt code and necessary modifier

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Reference no: EM133958468

Problem

Diagnosis: Family history of colon cancer

Procedure: Colonoscopy

Physician: Marion M. March, MD

Anesthesia: Versed 4 mg, Demerol 75 mg

PROCEDURE: Pt is a 59-year-old male presenting for a colonoscopy. Pt receives educational material and is informed of the risks. He acknowledges he understands the nature of the procedure, the risks, and the consequences, and consents to the procedure.

The patient is placed in the left lateral decubitus position. The rectal exam reveals normal sphincter tone and no masses. A colonoscope is introduced into the rectum and advanced to the distal sigmoid colon. Further advancement is impossible due to the marked fixation and severe angulation of the rectosigmoid colon. Procedure is discontinued.

On withdrawal, no masses or polyps are noted, and the mucosa is normal throughout. Rectal vault is unremarkable. The patient tolerates the procedure without difficulty.

IMPRESSION: Normal colonoscopy, only to the distal sigmoid colon

PLAN: Strong recommendation for a barium enema. Get the instant assignment help.

Determine the most accurate CPT code(s) and necessary modifier(s) for the colonoscopy.

Reference no: EM133958468

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