General Surgery Coding Alert

Question: Is there a code for an excision of an anorectal ulcer and Y-V anoplasty? The surgeon documented the following: Patient has a large ulcer. The area was excised using electrocautery down to subcutaneous tissue then a Y-V anoplasty was mapped out. Do I have to use unlisted code 46999?

Louisiana Subscriber

Answer: You should report either 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less) or 14041 (& defect 10.1 sq cm to 30.0 sq cm), depending on size. This code specifically includes VY anoplasty. The lesion excision is also included in the 14040 and 14041 codes, so you cannot separately report the excision, either.

--  Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPCOBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Childrens University Medical Group (CUMG) Compliance Program.