Appendix A 1.9 - Additional Medical Documentation for ...
Appendix A: 1.9 – Additional Medical Documentation for Gastroenterology ProceduresMedical documentation for gastroenterology procedures (e.g. colonoscopy, sigmoidoscopy, Esophagogastroduodenoscopy (EGD), Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic Ultrasonography ( EUS)) to be reported to the referring VA facility must include the following:Procedure performed (e.g. colonoscopy with biopsy)Procedural indicationSedation medications and dosesDescription of the quality of the bowel preparation (for colonoscopy or sigmoidoscopy)Depth of insertion of the endoscope/completeness of the procedureIf the procedure is incomplete, an explanation must be providedDescription of all relevant findings, for example:Number and size of polypsPresence of hemorrhoids, diverticulosis, colitis, stricture, etc.Full description of all interventionsIf polypectomy is performed, the provider must indicate whether or not the lesion was completely removed.Description of any unanticipated events or adverse eventsIf specimens were removed for pathologic assessment, then a copy of the pathology results must be includedSummary assessment and recommendations, including any recommended follow-up. If specimens were removed for pathologic assessment, then final recommendations taking into account the pathology results must be included ................
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