The OP note reads that the pediatric colonoscope was inserted into the rectum and advanced under direct vision to the terminal ileum. The findings showed evidence of prior surgery s/p total colectomy with illioanal pouch. Rectum/anus biopsy obtained; there was a stricture located in anus, dilated to a diameter of 0 mm using a through-the-scope dilating balloon digital exam performed. Biopsies obtained from friable area in anus.
Would I use the Pouchoscopy code 44386 with an unlisted code 44799 for the dilation?
re: Pouchoscopy with dilation of anus with biopsy?
If you use the unlisted code make sure you submit the complete op note. I believe that the dilation would be included in the procedure by most insurances since it was done through the scope. I checked with a pediatric surgeon who does these and she said that depending on the insurance it is included. You may want to contact the appropriate insurance and ask for guidance.