Appropriate procedure/service. A 42-year-old white male was referred to a gastroenterologist by his primary care physician because of a two-month history of gross rectal bleeding. The new patient was seen on Wednesday, and the doctor performed a comprehensive history and exam. Medical decision making was of moderate complexity. The patient was scheduled for a complete diagnostic colonoscopy four days later. The patient was given detailed instructions for the bowel prep that was to be started at home on Friday at 1:00 p. m.

On Friday, the patient was registered for outpatient surgery at the hospital, moderate conscious sedation (15 minutes) was administered by the physician performing the procedure, and the flexible colonoscopy was started. The examination had to be halted at the splenic flexure because of inadequate bowel preparation. The patient was rescheduled for Monday and given additional instructions for bowel prep to be performed starting at 3:00 p. m. on Sunday.

On Monday, the patient was again registered for outpatient surgery at the hospital, moderate conscious sedation (30 minutes) was again administered by the physician performing the procedure, and a successful total colonoscopy was performed. Diverticulosis was noted in the ascending colon and two polyps were excised from the descending colon using the snare technique. The pathology report indicated the polyps were benign.

Day of Encounter: Wednesday

Diagnosis:

Diagnosis Code:

Procedure: Level 4 E/M service, office, new patient (decision for surgery)

Procedure Code:

Day of Encounter: Friday

Diagnosis:

Diagnosis Code:

Procedure: Sigmoidoscopy (Colonoscopy was halted at sigmoid colon due to inadequate bowel prep)

Procedure Code:

Day of Encounter: Friday

Procedure: Moderate (conscious) sedation

Procedure Code:

Day of Encounter: Friday

Diagnosis:

Procedure Code: K62.5

Day of Encounter: Monday

Diagnosis:

Diagnosis Code:

Procedure: Colonoscopy, total, with removal of polyp

Procedure Code:

Day of Encounter: Monday

Procedure: Moderate (conscious) sedation

Procedure Code:
,

Day of Encounter: Monday

Diagnosis:
,

Diagnosis Code: D12.4