I have to correctly code these cases using 2017 CPT code book Surgical Case #3
Surgical Case #3
The patient was premedicated with a total of Fentanyl, 50 mcg, and Versed, 4 mg, intravenously.
The patient has presented with recurrent dysphagia. She has a history of a Schatzki’s ring, which has been dilated in the past.
The endoscope was inserted from the mouth into the esophagus without difficulty.
The esophageal mucosa was normal. A reformed Schatzki’s ring was located at the Z line, which was at approximately 29 cm. The endoscope could be inserted through this area with no resistance. The ring was located above a 3-cm hiatal hernia. The stomach, duodenal bulb, and descending duodenum were all normal. After the endoscope was withdrawn, a #60 French Maloney dilator was passed with very mild resistance. The patient tolerated the procedure well, and there were no immediate complications.
1. A reformed Schatzki’s ring, which was dilated
2. A 3-cm hiatal hernia