Procedure Flexible Pentax Question & Answer Guide (With Explanation)
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Original Question
PROCEDURE: The flexible Pentax video double channel endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 40 cm. Inspection of the esophagus revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The stomach proper was entered, and immediately seen in the antrum was erythema, friability, and some superficial gastric ulcerations, not bleeding. We entered the pylorus and could see a large 1.5-cm moderately deep duodenal bulb ulcer with no vessel or pigmented areas. Beyond this in the post-bulbar ulcer was a large 2-3 cm superficial post bulbar ulceration, not bleeding, without visible vessel. Photographs were obtained. On retroflexion, no lesions were seen. The patient tolerated the procedure well. IMPRESSION: 1. Moderate gastritis with superficial gastric ulcerations, not bleeding. 2. Duodenal bulb ulcer, 1.5 cm, moderately deep, with no vessel, clot, or pigmented areas. 3. A post-bulbar 2.5 to 3 cm (centimeter) stomach ulceration, superficial, not bleeding. SUGGESTIONS: 1. Continue IV (intravenous) Protonix. 2. Follow hemoglobins. What CPT code should be applied to this case?
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