Document Type: Colonoscopy Document Subject: Colonoscopy Performed By:  MD on November 09, 2022 14:05  Verified By:  MD on November 09, 2022 14:05  Encounter Info: Hospital, Outpatient in a Bed, 11/09/22 - 11/09/22 Contributor System:  * Final Report *  Colonoscopy  Hospital GI Dept.,   Health Patient Name:  Procedure Date: 11/9/2022 2:05 PM MRN:  Date of Birth:  Admit Type: Outpatient Age: 47 Gender: Female Attending MD: MD Procedure:             Colonoscopy Indications:           Rectal bleeding Providers:              MD Referring MD:          MD Medicines:             Fentanyl 100 micrograms IV, Midazolam 5 mg IV,                         Diphenhydramine 50 mg IV Complications:         No immediate complications. Estimated Blood Loss:  Estimated blood loss: none. Procedure:            The colonoscopy was                         performed without difficulty. The patient tolerated                         the procedure well. The quality of the bowel                         preparation was good. The ileocecal valve, appendiceal                         orifice, and rectum were photographed. Findings:      The digital rectal exam revealed a firm rectal mass. The mass was       non-circumferential and located predominantly at the left-posterior       bowel wall.      An ulcerated malignant looking non-obstructing medium-sized mass was       found in the distal rectum. The mass measured three cm in length with       the distal area very close to the dentate line/anorectal margin. No       bleeding was present. Biopsies were taken with a cold forceps for       histology.      The exam was otherwise normal throughout the examined colon up to cecum. Impression:            - Rectal mass.  Recommendation:        - Discharge patient to home.                        - Resume previous diet.                        - Continue present medications.                        - Await pathology results.                        Further work-up and plan after final pathology result. Procedure Code(s):     --- Professional ---                        45380, Colonoscopy, flexible; with biopsy, single or                         multiple                        99153, Moderate sedation; each additional 15 minutes                         intraservice time                        G0500, Moderate sedation services provided by the same                         physician or other qualified health care professional                         performing a gastrointestinal endoscopic service that                         sedation supports, requiring the presence of an                         independent trained observer to assist in the                         monitoring of the patient's level of consciousness and                         physiological status; initial 15 minutes of                         intra-service time; patient age 5 years or older                         (additional time may be reported with 99153, as                         appropriate) Diagnosis Code(s):     --- Professional ---                        K62.89, Other specified diseases of anus and rectum                        K62.5, Hemorrhage of anus and rectum All rights reserved. The codes documented in this report are preliminary and upon coder review may  be revised to meet current compliance requirements.  MD  MD 11/9/2022 3:04:51 PM This report has been signed electronically. Number of Addenda: 0 Note Initiated On: 11/9/2022 2:05 PM Procedure Date:        11/9/2022 2:05:42 PM Scope Withdrawal Time: 0 hours 8 minutes 47 seconds  Total Procedure Duration: 0 hours 17 minutes 11 seconds  Scope In: 2:15:48 PM Scope Out: 2:32:59 PM   Provation-Note This document has an image