Documentation of "random" biopsies by GI physicians
Hello to all.
Our coders are requesting further clarification from our GI physicians when they document "random biopsies" in their operative notes.
The coders are asking for the number of biopsies taken and the location in the colon: Ascending colon, Descending colon, Transverse colon, and Sigmoid colon.
Example:
Operative procedure: colonoscopy with biopsy
Preoperative dx: rectal bleeding and diarrhea
Postoperative dx: “NORMAL COLONIC AND TERMINAL ILEAL MUCOSA, RANDOM BIOPSIES TAKEN,” pan-diverticulosis, internal hemorrhoids, no bleeding identified
Specimen labeled “Random Colon” is a 1.2x0.8x01 cm
Pathology report: Colon, "random biopsy"
Procedure: After sedation by Anesthesiology, the Olympus PCF-H190DL video colonoscope was inserted through the anus, advanced to the level of the terminal ileum. The terminal ileum was identified by the terminal mucosa. The cecum was identified by the ileocecal valve. __________. The mucosa of the colon and terminal ileum appeared completely normal. There is no endoscopic evidence of colitis. There are no polyps, masses, lesions or AVMs identified. Multiple random biopsies were taken to rule out microscopic __________ given the patient's history of diarrhea. There was evidence of pan-diverticulosis. Upon withdrawal of the scope, careful examination was made revealing no further abnormalities. Upon inspection on retroflexion of the rectum, internal hemorrhoids were seen.
Is the above documentation sufficient for accurate coding of this procedure in the inpatient setting?
Or was it appropriate for the coder to query for further specificity?
Please advise.
Thank you in advance.
Comments
Need to know the anatomical locations of the biopsies to correctly code the procedure. We also require the Prodeduralist to specify the biopsy locations.
Jeff