AR2728
Expert
It is certainly a Monday for me, I'm having a little trouble on this one. I don't believe I can code 46060 as the description in my coding companion states ...mucosa, skin, and internal sphincter muscle overlying the fistula is incised and the fistula completely unroofed--for the fistulotomy part of the procedure. My op report documents only "overlying skin resection". Here is the op report:
Once his buttock cheeks were spread apart he did have an opening which was the site of what was felt to be a chronic abscess over his right ischium. This was 8 cm away from the anal verge at the 8- o'clock position on the right buttocks. This was over the medial ischium. The patient did have an approximately 1 cm bulge with some granulation tissue with purulence expressed. A rectal probe was brought up and was passed into the opening and did easily direct down towards the posterior midline anal gland. It became apparent that this was not simply a skin abscess which was not healing because of constant pressure or a foreign body but instead was a perianal abscess with fistula. The patient subsequently had local anesthetic administered around the site of the abscess and was given Cefoxitin 2 grams. A 20-25 X 8-10 mm ellipse was resected around the opening with the bulge at the opening resected and the overlying skin resected down to the underlying subcutaneous tissues. The fistula tract was easily visualized. The patient did undergo slow dilatation to 3 fingertips employing the Lord's technique and the small silver anoscope was inserted with some scarring and inflammation in the posterior midline anal gland. The patient also had some hemorrhoid inflammation. Employing gentle probing the tract was gently probed and with various size probes the tract was able to be probed without pressure and did come out through the posterior midline anal gland. This did come out without resistance and was placed in the rectal vault itself.Under direct vision through the anoscope the probe was then grasp and brought out through the
rectum. A #2 Ethibond suture was pulled through the fistula tract and out through the anus by pulling the probe through the tract. This was then tied to itself against the skin several times and then a second knot about 5 cm distal to that with the ends of the Ethibond suture to itself in the form of a cutting Seton. Anoscopy revealed good drainage through the posterior midline anal gland with the hemorrhoids noted above. The patient had easy probing to the posterior midline anal gland but because of the length of the area it did take careful probing to have it come out through the actual anal gland without resistance. It did drop through the opening and come out without any resistance and the fistula tract was able to be negotiated and Seton placed.....
I believe I'm left with only 46020 as per CCI edits 46040 is part of the primary 46020 procedure.
Once his buttock cheeks were spread apart he did have an opening which was the site of what was felt to be a chronic abscess over his right ischium. This was 8 cm away from the anal verge at the 8- o'clock position on the right buttocks. This was over the medial ischium. The patient did have an approximately 1 cm bulge with some granulation tissue with purulence expressed. A rectal probe was brought up and was passed into the opening and did easily direct down towards the posterior midline anal gland. It became apparent that this was not simply a skin abscess which was not healing because of constant pressure or a foreign body but instead was a perianal abscess with fistula. The patient subsequently had local anesthetic administered around the site of the abscess and was given Cefoxitin 2 grams. A 20-25 X 8-10 mm ellipse was resected around the opening with the bulge at the opening resected and the overlying skin resected down to the underlying subcutaneous tissues. The fistula tract was easily visualized. The patient did undergo slow dilatation to 3 fingertips employing the Lord's technique and the small silver anoscope was inserted with some scarring and inflammation in the posterior midline anal gland. The patient also had some hemorrhoid inflammation. Employing gentle probing the tract was gently probed and with various size probes the tract was able to be probed without pressure and did come out through the posterior midline anal gland. This did come out without resistance and was placed in the rectal vault itself.Under direct vision through the anoscope the probe was then grasp and brought out through the
rectum. A #2 Ethibond suture was pulled through the fistula tract and out through the anus by pulling the probe through the tract. This was then tied to itself against the skin several times and then a second knot about 5 cm distal to that with the ends of the Ethibond suture to itself in the form of a cutting Seton. Anoscopy revealed good drainage through the posterior midline anal gland with the hemorrhoids noted above. The patient had easy probing to the posterior midline anal gland but because of the length of the area it did take careful probing to have it come out through the actual anal gland without resistance. It did drop through the opening and come out without any resistance and the fistula tract was able to be negotiated and Seton placed.....
I believe I'm left with only 46020 as per CCI edits 46040 is part of the primary 46020 procedure.