AHA Coding Clinic® for HCPCS - 2008 Issue 2

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A 38-year-old female with a history of subtotal colectomy and ileorectal anastomosis due to ulcerative colitis presents to our facility for proctoscopy and ileoscopy with biopsy. The patient requests sedation for this procedure despite the limited length of gastrointestinal tract to be examined. IV sedation was performed and following a digital rectal examination, a colonoscope was introduced into the rectum and was advanced for 10 cm. The rectal stump measured about 5 to 6 centimeters and the ileum was then examined for a few centimeters. Biopsies were obtained for histologic examination from the ileum and rectal mucosa. How would the proctoscopy and ileoscopy with biopsy be appropriately coded? ...

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