Using the coding techniques you have learned, carefully read through the case study and determine the most accurate procedure code(s) and modifier(s), if appropriate.

GREGORY SAME DAY SURGERY

955 East Healthcare Boulevard SOMEWHERE, FL 32811 407-555-1597

PATIENT:GILMORE, STEVEN

ACCOUNT/EHR #:GILMST001

DATE:09/13/18

Diagnosis:Family history of colon cancer

Procedure:Colonoscopy

Physician:Marion M. March, MD

Anesthesia:Versed 4 mg, Demerol 75 mg

PROCEDURE:Pt is a 59-year-old male presenting for a colonoscopy. Pt receives educational material and is informed of the risks. He acknowledges he understands the nature of the procedure, the risks, and the consequences, and consents to the procedure.

The patient is placed in the left lateral decubitus position. The rectal exam reveals normal sphincter tone and no masses. A colonoscope is introduced into the rectum and advanced to the distal sigmoid colon. Further advancement is impossible due to the marked fixation and severe angulation of the rectosigmoid colon. Procedure is discontinued.

On withdrawal, no masses or polyps are noted, and the mucosa is normal throughout. Rectal vault is unremarkable. The patient tolerates the procedure without difficulty.

IMPRESSION:Normal colonoscopy, only to the distal sigmoid colon

PLAN:Strong recommendation for a barium enema

MMM/mg D: 09/13/18 09:50:16 T: 09/13/18 12:55:01

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).

You may not need all of the spaces provided.