WebSite: www.drdahlstedt.com COLONOSCOPY PREP WITH BISACODYL AND MIRALAX
Your examination is scheduled for ____________________, ____________________ @ :
William Beaumont Hospital –Troy, West Entrance:
44201 Dequindre Rd, Troy, MI 48085 Phone #: 248-964-5122 Rochester Endoscopy & Surgery Center: 2700 S. Rochester Rd, Rochester Hills, MI 48307 Phone #: 248-844-3800
You will be called by our office or the hospital 24 to 48 hours prior to the procedure as to the exact time to arrive. One week before your colonoscopy:
1. Thoroughly read all of your prep instructions. 2. Review our recommendations about taking certain blood thinners. Call us if you have
any questions. Our office hours: Monday thru Friday 8:00am – 4:30pm.
3. Arrange for a driver for your procedure.
4. Avoid grainy breads, granola, nuts, seeds, raw fruits and vegetables with seeds, and
popcorn for at least three days before your procedure.
Two or more days before your colonoscopy:
1. Complete any forms you may have received as far as your history and current medications.
Bring names and addresses of any physicians you wish to receive a copy of the report
2. Obtain the bowel prep products from your pharmacy:
1. Bisacodyl 5mg tablets (Dulcolax, Alophen, and other brands) either four (4) or six
(6) tablets depending on constipation tendency.
2. PEG 3350 Powder (e.g. Miralax) approx. 238 gram bottle. 3. Purchase 64 ounces of a clear liquid sports drink such as Gatorade, Propel, G2,
4. Barrier creams to soothe your bottom: Vaseline, zinc oxide, or Calmoseptine.
3. If you have a tendency for constipation, you will ease the cleansing phase by taking a laxative such as bisacodyl, senna, milk of magnesia, or citrate of magnesia 2-3 days before the procedure to get things started and ease the final day’s preparation.
One day before your procedure:
1. You may have a low residue breakfast and lunch before 1:00 pm. (Example: scrambled eggs,
cooked cereal, yogurt, cottage cheese, pancake or waffles, white bread, fruit cocktail).
2. Drink ample clear liquids throughout the day.
3. Between 8:00 am and 11:00 am take four (4) bisacodyl tablets.
4. After a low residue lunch, you may only have clear liquids. NO SOLID FOOD. Clear Liquid Diet
▪ Water, plain coffee(sugar is allowed), tea, clear juices (apple or white grape), lemonade (no pulp), Fruit
flavored drinks ex: powder drinks , sodas. flavored waters , sports drinks, etc.
▪ Fat free broth / bouillon / consommé
▪ Plain / flavored Jello®, fruit ices / Italian ices, sorbet popsicles (without milk or added fruit pieces)
5. Mix the whole 238 gram bottle of PEG 3350 (Miralax) powder with two quarts (64 oz.) of
Gatorade or other clear liquid, until dissolved. Keep cold in refrigerator.
6. Between 4:00 and 6:00 pm begin drinking the powder/Gatorade solution. Drink one (1) 8 oz.
glass every 15-30 minutes until finished. Do your best to drink this solution over 2 hours. If nauseated slow down, take a break, and restart as soon as possible.
7. If your procedure is scheduled for 11:00 am or later, you have the option of a split dose prep
which allows a better cleaning. You should drink half of the solution in the evening and half in the early morning, 5-6 hours before your scheduled test and having nothing by mouth for 4 hours before procedure. Anesthesia requires nothing by mouth for four (4) hours before the procedure.
8. Expect several frequent bowel movements. Stay close to a restroom. A thorough bowel prep is
achieved when there is no solid content and the return is nearly clear liquid.
9. You may liberally apply a barrier ointment such as Vaseline, zinc oxide, or Calmoseptine to the
rectal area after each stool to help avoid discomfort from the frequent stools.
10. Have nothing to drink after midnight if procedure is before 11:00 am. Have nothing to drink for 4
hours before your procedure if doing the split regimen (procedure is 11:00 am or after).
The day of your colonoscopy:
1. Except as advised, you may take any of your regularly prescribed morning medications with a
small amount of clear liquid. Be sure to take your usual blood pressure and heart medications.
2. Nothing else to eat or drink for 4 hours prior to your procedure.
3. You must have a companion/driver wait during the procedure and drive you home.
4. You can expect to be at the facility or hospital for a total of 1 ½ to 3 hours.
5. If you have any questions please call our office at (586) 254-7955. For problems or questions
that arise on the day of the procedure please contact the facility or hospital at the numbers listed on page 1.
Please carry a list of all medications that you take and the amount you take. Include vitamins, herbal supplements and over-the-counter drugs. Always tell your doctor and nurse about any allergies, side effects or problems you have had with medications.
You may be asked to hold some of the following blood thinners, depending on the type of procedure that you are having and the condition for which you are taking these medications:
NSAIDS WITH ANTI-PLATELET EFFECT: Generic Name for Medicine Brand Name How Long to Hold Medicine
Arthrotec, Cataflam, Voltaren, Voltaren XR
SPECIFIC ANTI-PLATELET AGENTS: Generic Name for Medicine Brand Name How Long to Hold Medicine ANTICOAGULANT AGENTS: Generic Name for Medicine Brand Name How Long to Hold Medicine General Medication Notes:
1. Do not take antidiarrheal medications (Imodium, Lomotil) or irritable bowel medications (Bentyl, Levsin,
Donnatal, hyoscyamine) while prepping for your procedure.
2. If you are diabetic and:
On insulin: take half your usual insulin dose on the day before your procedure and morning of your procedure.
On oral diabetic medications: do not take these medications on the day before and morning of your procedure.
Before your procedure you will be taken to a pre-procedure room where an I.V. will be started and a nurse will assist you in preparing for your procedure. You will be given medications through the I.V. to facilitate a comfortable procedure. Once your procedure is completed you will go to a recovery room. Your companion/family member will be allowed to visit in this area. Your doctor will speak to you about the results of the procedure at this time. Your stay in this area is usually less than one hour. Here your I.V. will be removed and soon after you will be discharged home. Revised 07/22/2011
BILLING INFORMATION FOR YOUR OUTPATIENT PROCEDURE
Whether your procedure is done at William Beaumont Hospital, Troy or Rochester Endoscopy & Surgery Center, there may be up to five (5) separate providers billing your insurance company: the doctor himself, the facility, the anesthesiologist, the lab that preps the pathology, and the pathologist. You should receive an EOB (Explanation of Benefits) from your insurance company for any of these services. You may then receive a bill for any balance from each of the providers. If you have a billing question from any provider other than our office, please contact them directly. We can only answer questions regarding OUR charges.
SCREENING COLONOSCOPY AND YOUR INSURANCE
A screening colonoscopy is considered a preventative benefit and may or may not be a covered benefit under your insurance policy. Please be advised that we urge you to contact your insurance company for verification. For patients who are over age 50 and have no family history of colon cancer, no personal history of colon polyps, and have no symptoms, the procedure code to verify with your insurance for coverage is procedure code G0121 and the diagnosis code is V76.51. This stands for screening colonoscopy (average risk) and screening for malignant neoplasm of the colon. For patients who have a family history of colon cancer (biological mother, father, sister, or brother), personal history of colon cancer, personal history of colon polyps, family history of colon polyps (familial adenomatous polyposis), or inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, the procedure code to verify with your insurance is procedure code G0105. The diagnosis code is as follows: V16.0 – immediate family history of colon cancer V10.05 – personal history of colon cancer V10.06 – personal history of rectal cancer V18.51 – family history of colon polyps V12.72 – personal history of colon polyps 555.9 – Crohn’s disease 556.9 – ulcerative colitis Procedure code G0105 stands for screening colonoscopy (high risk) IMPORTANCE NOTICE: SHOULD A PHYSICIAN NEED TO TAKE A BIOPSY OR REMOVE A POLYP(S) THE COLONOSCOPY IS NO LONGER CODED AS A SCREENING COLONOSCOPY. YOUR BENEFITS MAY CHANGE. THE DIAGNOSTIC CODES ARE 45380, 45383, 45384, AND 45385.
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WebSite: www.drdahlstedt.com 
BILLING INFORMATION FOR YOUR OUTPATIENT PROCEDURE