A patient who is status post-sigmoid colectomy with Hartmann pouch and colostomy has developed a

A patient who is status post-sigmoid colectomy with Hartmann pouch and colostomy has developed a stenotic stoma. The patient presents weekly for either digital dilation or dilation with a Hagar dilator in the office. Documentation includes the following: Performed stoma dilation with an 11/12-Hagar dilator with both ends passing easily after initial pass. May this be reported separately using an unlisted CPT code, or is it included in an evaluation and management (E/M) service?

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CPT Knowledgebase - Oct 4, 2018