Colonoscopy Surgery Operative Report
- Medycoding Expert
- Mar 10
- 14 min read
Op report 1 : Colonoscopy
Patient Name : ABC Insurance : Blue Cross
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication : Rectal Bleeding
Anesthesia : Monitored Anesthesia care
Complication : None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
Throughout the examination, scattered diverticula were noted in the descending and sigmoid colon, consistent with diverticulosis. No evidence of active diverticulitis, perforation, or stricture was observed.
The rectum and sigmoid colon displayed mild erythematous mucosa, suggestive of proctosigmoiditis. No ulcers, friability, or exudates were present.
Internal hemorrhoids (Grade I) were noted during retroflexion, appearing non-bleeding and non-thrombosed.
Mild colonic spasm was observed in the transverse colon, but no strictures, mass lesions, or obstructive findings were present.
No polyps, tumors, or suspicious lesions were identified during the examination.
The remainder of the colonic mucosa appeared normal, with no evidence of bleeding, inflammation, or malignancy.
Impression:
- Scattered diverticula in the descending and sigmoid colon, consistent with diverticulosis.
- Mild erythematous mucosa in the rectum and sigmoid colon, suggestive of proctosigmoiditis.
- Internal hemorrhoids (Grade I) without active bleeding.
- Mild colonic spasm observed in the transverse colon.
- No polyps, masses, or malignancies visualized.
- The examination was otherwise normal.
Answer:
ICD : Rectal bleeding : K62.5
Diverticula of colon : K57.30
Erythematous of rectum and colon : K62.89.K63.89
Internal hemorrhoid (Grade 1) : K64.0
Colonic spasm : K58.9
CPT : 45378
Op report 2 :
Patient Name : ABC Insurance : Medicare
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Colon cancer screening, Family history of colon cancer, Personal history of adenomatous polyps in descending colon
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
Throughout the examination, scattered diverticula were noted in the descending and sigmoid colon, consistent with diverticulosis. No evidence of active diverticulitis, perforation, or stricture was observed.
The rectum and sigmoid colon displayed mild erythematous mucosa, suggestive of proctosigmoiditis. No ulcers, friability, or exudates were present.
Internal hemorrhoids (Grade 2) were noted during retroflexion, appearing non-bleeding and non-thrombosed.
No polyps, tumors, or suspicious lesions were identified during the examination.
The remainder of the colonic mucosa appeared normal, with no evidence of bleeding, inflammation, or malignancy.
Impression:
- Scattered diverticula in the entire colon.
- Mild erythematous mucosa in the rectum and sigmoid colon, suggestive of proctosigmoiditis.
- Internal hemorrhoids (Grade 2) without active bleeding.
- No polyps, masses, or malignancies visualized.
- The examination was otherwise normal.
Answer
ICD : Colon cancer Screening : Z12.11
Family History of colon cancer : Z80.0
Personal history of colon polyps : Z86.0101
Diverticula of colon : K57.30
Erythematous of rectum and colon : K62.89.K63.89
Internal hemorrhoid (Grade 2) : K64.1
CPT : G0105 (High risk Screening)
Op report 3 :
Patient Name : ABC Insurance : Medicare
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Colon cancer screening
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
Throughout the examination, scattered diverticula were noted in the descending and sigmoid colon, consistent with diverticulosis. No evidence of active diverticulitis, perforation, or stricture was observed.
The rectum and sigmoid colon displayed mild erythematous mucosa, suggestive of proctosigmoiditis. No ulcers, friability, or exudates were present.
Internal hemorrhoids (Grade 3) were noted during retroflexion, appearing non-bleeding and non-thrombosed.
2 polyps were identified in the ascending colon during the examination.
The remainder of the colonic mucosa appeared normal, with no evidence of bleeding, inflammation, or malignancy.
Impression:
- Scattered diverticula in the entire colon.
- Mild erythematous mucosa in the rectum and sigmoid colon, suggestive of proctosigmoiditis.
- Internal hemorrhoids (Grade 3) without active bleeding.
- 2 Polyps were identified.
- The examination was otherwise normal.
Answer
ICD : Colon cancer Screening : Z12.11
Diverticula of colon : K57.30
Erythematous of rectum and colon : K62.89.K63.89
Internal hemorrhoid (Grade 3) : K64.2
Ascending colon Polyps : K63.5
CPT : G0121 (Low risk Screening)
Op report 4
Patient Name : ABC Insurance : Aetna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Diarrhea
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
A 6 mm flat polyp was identified in the ascending colon. A cold snare polypectomy was performed, and the polyp was successfully retrieved with minimal blood loss.
Scattered diverticula were present in the descending and sigmoid colon, consistent with diverticulosis.
Retroflexion in the rectum revealed Internal hemorrhoids without active irritation or thrombosis. No additional abnormalities were observed.
Impression:
- One benign appearing 5 mm polyp in the ascending. Resected and retrieved.
- Diverticulosis in the descending colon and sigmoid colon.
- Non-bleeding internal hemorrhoids.
- The examination was otherwise normal.
Answer
ICD : Ascending colon Polyps : K63.5
Diverticulosis of colon : K57.30
Non bleeding Internal hemorrhoid: K64.9
Diarrhea is the symptom of colon polyps
CPT : 45385 (Removal of colon polyps via Snare technique)
Op report 5
Patient Name : ABC Insurance : Aetna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Constipation
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
A 6 mm flat polyp was identified in the ascending colon. A cold snare polypectomy was performed, and the polyp was successfully retrieved with minimal blood loss.
Two 3mm polys were found in descending so resected with Cold Forceps.
Scattered diverticula were present in the descending and sigmoid colon, consistent with diverticulosis.
Retroflexion in the rectum revealed Internal hemorrhoids without active irritation or thrombosis. No additional abnormalities were observed.
Impression:
- One benign appearing 5 mm polyp in the ascending. Resected and retrieved.
- Two benign appearing 3 mm polyp in the descending. Resected and retrieved.
- Diverticulosis in the descending colon and sigmoid colon.
- Non-bleeding internal hemorrhoids.
- The examination was otherwise normal.
Answer
ICD : Ascending colon Polyps : K63.5
Diverticulosis of colon : K57.30
Non bleeding Internal hemorrhoid: K64.9
CPT : 45385 (Removal of colon polyps via Snare technique)
45380- 59 (Removal of colon polyps via Cold forceps )
Op report 6
Patient Name : ABC Insurance : Medicare
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Colorectal cancer screening
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
A 6 mm flat polyp was identified in the ascending colon. A cold snare polypectomy was performed, and the polyp was successfully retrieved with minimal blood loss.
Two 3mm polys were found in descending cold so resected with Cold Forceps.
Scattered diverticula were present in the descending and sigmoid colon, consistent with diverticulosis.
Retroflexion in the rectum revealed Internal hemorrhoids without active irritation or thrombosis. No additional abnormalities were observed.
Impression:
- One benign appearing 5 mm polyp in the ascending. Resected and retrieved.
- Two benign appearing 3 mm polyp in the descending. Resected and retrieved.
- Diverticulosis in the descending colon and sigmoid colon.
- Non-bleeding internal hemorrhoids.
- The examination was otherwise normal.
Answer
ICD : Ascending colon Polyps and descending : K63.5
Diverticulosis of colon : K57.30
Non bleeding Internal hemorrhoid: K64.9
CPT : 45385-PT (Removal of colon polyps via Snare technique)
45380-59-PT (Removal of colon polyps via Cold forceps )
Op report 7
Patient Name : ABC Insurance : Cigna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: Haematochezia, Personal History of Colonic Polyps
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
A benign appearing sessile polyp was found in the rectum. The polyp was 5 mm in size. The polyp was removed using a cold snare. Resection and retrieval were complete. Estimated blood loss was minimal.
A pedunculated polyp was found in the sigmoid colon. The polyp was 7 mm in size. The polyp was removed with a hot biopsy forceps. Resection and retrieval were complete.
Multiple large-mouthed diverticula were found in the descending colon.
Non-bleeding prolapsed internal hemorrhoids were found during retroflexion and were Grade II (internal hemorrhoids that prolapse but reduce spontaneously). The exam was otherwise without abnormality.
Impression:
- One benign appearing 5 mm polyp in the rectum. Resected and retrieved.
- One 7 mm polyp in the sigmoid colon. Resected and retrieved.
- Diverticulosis in the descending colon.
- Non-bleeding prolapsed internal hemorrhoids.
- The examination was otherwise normal.
Answer
ICD : Sigmoid colon Polyps : K63.5
Rectal Polyps : K63.1
Diverticulosis of colon : K57.30
Non bleeding Internal hemorrhoid: K64.9
CPT : 45385 (Removal of colon polyps via Snare technique)
45384-59 (Removal of colon polyps via Hot forceps )
Op report 8
Patient Name : ABC Insurance : Aetna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: A 64-year-old male with a history of intermittent rectal bleeding and recent episodes of hematochezia presented for a colonoscopy to evaluate the source of bleeding and determine the appropriate management.
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
A thorough inspection was performed during both insertion and withdrawal.
During retroflexion in the rectum, actively bleeding Grade III internal hemorrhoids were identified. There was evidence of recent hemorrhage but no active pulsatile bleeding at the time of examination. Bipolar coagulation was applied to the most engorged vessels to achieve hemostasis.
Further examination revealed angiodysplasia in the ascending colon with active oozing of blood. Haemostasis was achieved using argon plasma coagulation (APC) with cessation of bleeding confirmed before withdrawal.
Scattered diverticula were observed in the sigmoid and descending colon, consistent with diverticulosis, but no signs of active diverticular bleeding were present.
The remainder of the colonic mucosa appeared normal, with no ulcers, strictures, or malignant lesions identified.
Impression:
- Actively bleeding internal hemorrhoids (Grade III) with stigmata of recent hemorrhage.
- Angiodysplasia in the ascending colon with active oozing, successfully treated.
- Scattered diverticulosis in the sigmoid and descending colon.
- No evidence of mass lesions, polyps, or malignancy.
Answer
ICD : Angiodysplasia of colon with oozing : K55.21
Grade 3 Internal hemorrhoid: K64.2
CPT : 45382 (Colonoscopy with control of bleeding)
Op report 9
Patient Name : ABC Insurance : Aetna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: A 57-year-old male with a history of colonic polyps on prior screening colonoscopy presented for surveillance and therapeutic resection of previously identified polyps.
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
In the ascending colon, two sessile polyps measuring 15 mm and 12 mm were identified. A submucosal saline injection was performed to lift the lesions, and endoscopic mucosal resection (EMR) was carried out using a snare technique. The polyps were completely resected, and retrieval was successful. No immediate bleeding was observed.
In the sigmoid colon, a 10 mm sessile polyp was visualized and similarly resected via EMR following submucosal injection. The specimen was retrieved, and hemostasis was confirmed.
Scattered diverticula were noted in the sigmoid and descending colon, consistent with diverticulosis, but no signs of active bleeding or inflammation were present.
The remainder of the colonic mucosa appeared normal, with no ulcerations, strictures, or additional polyps detected.
Impression:
- Two sessile polyps (15 mm and 12 mm) in the ascending colon, successfully resected.
- One 10 mm sessile polyp in the sigmoid colon, successfully resected.
- Scattered diverticulosis in the sigmoid and descending colon.
- No evidence of mass lesions, polyps, or malignancy.
Answer
ICD : Polyps of colon : K63.5
Diverticulosis of colon: K64.2
CPT : 45385 ( Snare resection of polyps)
45381-51 (Submucosal injection )
Op report 10
Patient Name : ABC Insurance : Aetna
Date of Birth : 20/03/1996 Admit Type : Outpatient
Procedure Date : 13/02/2026 Gender : Male
Indication: A 57-year-old male with a history of colonic polyps on prior screening colonoscopy presented for surveillance and therapeutic resection of previously identified polyps.
Medication: Monitored Anesthesia Care
Complication: None
Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. After I obtained informed consent, the scope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.
The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ileocecal valve. The colonoscopy was performed without difficulty. The patient tolerated the procedure well. The quality of the bowel preparation was good.
Findings:
In the ascending colon, two sessile polyps measuring 15 mm and 12 mm were identified. A submucosal saline injection was performed to lift the lesions. Demarcation of the lesion was enhanced by techniques such as high-definition white light, narrow-band imaging (NBI), or cautery, ensuring clear visualization of lesion boundaries. Following this, endoscopic mucosal resection (EMR) was carried out using a snare technique. The polyps were completely resected, and retrieval was successful. No immediate bleeding was observed.
In the sigmoid colon, a 10 mm sessile polyp was visualized and similarly resected via EMR following submucosal injection. Lesion demarcation was improved using advanced imaging techniques before snare excision. The specimen was retrieved, and hemostasis was confirmed.
During further examination, multiple scattered diverticula were noted in the sigmoid and descending colon, consistent with diverticulosis, but no active bleeding was observed.
The rectal mucosa appeared mildly erythematous, suggestive of mild proctitis, without ulceration or friability.
Retroflexion in the rectum revealed Grade I internal hemorrhoids, non-bleeding and non-thrombosed.
Impression:
- Two sessile polyps (15 mm and 12 mm) in the ascending colon, successfully resected.
- One 10 mm sessile polyp in the sigmoid colon, successfully resected.
- Multiple scattered diverticula in the sigmoid and descending colon, consistent with diverticulosis.
- Mild erythematous mucosa in the rectum, suggestive of mild proctitis.
-Non-bleeding internal hemorrhoids (Grade I) on retroflexion.
Answer
ICD : Encounter for Surveilance for colonoscopy : Z12.11
Polyps of colon : K63.5
Diverticulosis of colon: K57.3
Erythematous of rectum : K62.89
Non-bleeding internal hemorrhoid (Grade 1) : K64.0
CPT : 45390-33 ( Colonoscopy, flexible; with endoscopic mucosal resection)