Operative report
PREOPERATIVE DIAGNOSIS: Questionable stenosis of rectal anastomosis. POSTOPERATTVE DIAGNOSIS: Stenosis of rectal anastomosis.
PROCEDURE: Flexible sigmoidoscopy with dilatation of rectal anastomosis.
ANESTHESIA: Intravenous.
PROCEDURE: This 7-year-old female patient was brought to the endoscopy suite and placed in the left lateral decubitus position. A pediatric colonoscope was passed without difficulty though the anus. At 10 cm on the scope, the patient was found to have stenosis at the site of a previous rectal anastomosis. The anastomosis was very gently dilated until it could admit the scope. The scope was then passed through the anastomosis to the sigmoid colon where evaluation noted fairly normal anatomical features. The scope was then slowly withdrawn and the procedure terminated. The patient was returned to the recovery room is satisfactory condition.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
What will be an ideal response?
Answers:
ICD-9-CM diagnosis code(s): 569.2
ICD-10-CM diagnosis code(s): K62.4
CPT code(s) with modifier, if applicable: 45340
APC: 146
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