yes, you should type both - they are two different procedures
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if in doubt, give us the entire sentence so we can see what the issue is.
Just to clear this up for the OP - sm
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An endoscopy is literally just "looking inside". It can be an upper endoscopy- what most consider an EGD if there has been no surgery changing the anatomy and it can be a lower endoscopy which is usually referring to a colonoscopy. Some doctors never say upper or lower endoscopy; some doctors never say EGD or colonoscopy.
The only way to know what he means is in context. If he sees stomach and ileum, he's doing an AND. If only one or the other, he is just one of those guys who is redundant, like colonic colon polyps.
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That was "dictator from H-E-double-toothpicks" day. Below is what was returned from QA. (I actually got kudos for doing as well as I did as a 2-wk-old newbie. QA acknowledged this was our absolute worst dictator.)
SENTENCE: She is still due to get an endoscopy, colonoscopy for workup of weight loss and iron deficiency anemia.
Note from November 1 for a combined colonoscopy and endoscopy. It documents postoperative diagnoses of: 1. Multiple sequel diverticula. 2. Suboptimal colonic prep. 3. Mild gastritis. 4. SOUNDS LIKE "Probable gastro preocism"
PLEASE HELP! The only thing I am coming up with that remotely makes sense is Probable gastral, preexisting. ??? ...
Stomach _________ was remarkable only for some minimal suggestion of antral gastritis with hyperemia and focal hypervascularity.
He speaks perfectly clear English, so it's not the b/v switcheroo. I've had no luck in word books, anatomy books, or Google. ...
We also proceeded with an upper endoscopy as well. Upper endoscopy showed that her gastric remnant only had mild nonspecific erythema. I explored the surgical (lumen) and found that this was completely normal.
FYI- The pt also has a history of gastric resection and a known surgical anastomosis, but the word in question is not anastomosis.
It s/l lumen or limb or lamen.
Any ideas?
Thanks. ...
I am transcribing a colonoscopy report and the doctor states, "...The cecum was reached and identified. The light translumen in the right lower quadrant. The ileocecal valve was noted."
I am having a hard time hearing, "The light translumen in the right lower quadrant." The light translumen is the difficult part to hear. This doesn't make sense to me.
Could this be correct?
(P.S.- he typically leaves verbs out, so it could be - was in the right lower quadran ...
"Examination of the colon revealed mild colitis characterized by tiny mucopurulent (spots) in the transverse and descending colon."
The word he uses acutally sounds like spock. Could be spots but I just want to see if anyone knows something different?
Thanks. ...
Op report reason: Screening and Diarrhea. Colonoscopy done, polyp found and removed. The reason for the colonoscopy is both Screening and Diarrhea. In fact, doc documents prime reason for colonoscopy is screening and second reason diarrhea. What is the diagnosis code for this? If a coder has to code by the documentation and the doctor's final answer is that it is for both a screening and for diarrhea, what is a coder to do?&n ...
Dictated: there was a small polyp in the cecum which was removed using large s/l bodding biopsy forceps.
bodding, body-and, biting, bodine... I hear the 'b' at the start, the 't' or 'd' in the middle, and 'ing' or 'ine' on the end.
Any suggestions? Thanks! ...
Endoscopy showed findings of moderate stenosis extending from 40 to 43 cm, with a "ZMI" of 42 cm with friable esophageal tissue with associated blood clot proximal to this region. ...