Question

A 20 year-old patient presented to the hospital with a history of bloody stools for three weeks' duration. the patient was prepped for a sigmoidoscopy. the sigmoidoscope was passed without difficulty to about 40 cm. the entire mucosal lining was erythematosus. there was no friability of the overlying mucosa and no bleeding noted. no pseudo polyps were identified. biopsies were taken at about 30 cm; these were thought to be representative of the mucosa in general. the scope was retracted; no other abnormalities were seen. what cpt® and icd-10-cm codes are reported?

Answer 1

The answer is 45331, K92.1. CPT® code for a sigmoidoscopy with single or various biopsies is accounted for 45331. This is recorded under Sigmoidoscopy/Biopsy. Symptomatic sigmoidoscopy is constantly packaged with a surgical sigmoidoscopy when both are performed in a similar agent session. The ICD-10-CM code for bleeding stools is found in the Index to Diseases and Injuries under Blood/in/defecation or Hematochezia or Melena and coded K92.1. At the point when a patient comes in with a GI side effect and no conclusive analysis is reported for the indication.