[Answered]: Assign ICD-10-CM, HCPCS Level II, and CPT codes…

Assign ICD-10-CM, HCPCS Level II, and CPT codes where applicable.2. Determine whether the documentation for the surgical procedure is complete or incomplete.3. If the documentation is incomplete, assign a compliant physician query. If the documentation is complete, list N/A.Case 1:55-year-old female here today for diagnostic colonoscopy. Patient has been experiencing rectal bleeding intermittently for the last month. Pre-operative diagnosis: Rectal BleedingPost-operative diagnosis: Colon polyp Anesthesia: Propofol 120 mg Procedure Performed: Diagnostic colonoscopy with polyp removal A physical exam was performed. Informed consent was obtained from the patientafter explaining all of the risks (perforation, bleeding, infection and adverse effects to the medication), benefits and alternatives to the procedure which the patient appeared to understand and so stated. The patient was connected to the monitoring devices and placed in the left lateral position. Continuous oxygen was provided with a nasal cannula and IV medicine administered through an indwelling cannula. After adequate conscious sedation was achieved, a digital exam was performed, and the colon scope introduced into the rectum and advanced under direct visualization to the terminal ileum. A polyp was identified descending colon and removed. The scope was then withdrawn. Electronically Signed By: John Smith, MD 6/2/2021 8:00am