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GREGORY SAME DAY SURGERY 955 East Healthcare Boulevard • SOMEWHERE, FL 32811 • 407-555-1597 PATIENT: RISHER, BELVA ACCOUNT/EHR #: RISHBE001 DATE: Diagnosis: Fecal incontinence, diarrhea, constipation Procedure: Total colonoscopy with hot biopsy destruction of sessile 3-mm mid-sigmoid colon polyp and multiple cold biopsies taken randomly throughout the colon Physician: Marion M. March, MD Anesthesia: Demerol 50 mg and Versed 3 mg, both given IV PROCEDURE: Pt is a 43-year-old female. Patient was placed into position. Digital examination revealed no masses. The pediatric variable flexion Olympus colonoscope was introduced into the rectum and advanced to the cecum. A picture was taken of the appendiceal orifice and the ileocecal valve. The scope was then carefully extubated. The mucosa looked normal. Random biopsies were taken from the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum. There was a 3-mm sessile polyp in the mid-sigmoid colon that a hot biopsy destroyed. IMPRESSION: Sigmoid colon polyp destroyed by hot biopsy RECOMMENDATIONS: Follow-up in 7 days for biopsy results. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. Determine the most accurate CPT code(s) and necessary modifier(s) for the colonoscopy. The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

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