Cauterization of rectal bleeding under anesthesia

jmliles

New
Messages
3
Location
Vienna, VA
Best answers
0
If a provider performs an anoscopy under anesthesia with cauterization of rectal bleeding, would that be billed with 45990 or 46614?
 

lcolborn

Networker
Messages
56
Best answers
0
What was the cause of the bleeding? What did he cauterized ....., Is it an incision of a thrombosed hemmorhoids, destruction etc? . I just want to establish the procedure and the problem first before giving my opinion.
 

jmliles

New
Messages
3
Location
Vienna, VA
Best answers
0
Bleeding was coming from prolapsing mucosa. Here is a snip-it from the op note. Thanks for your help!

An anoscopy was performed with the examination of the anal canal to approximately 8 cm from the verge. There was old clot that was evacuated, approximately 50 cc. There was very mild active bleeding noted from the area just above the dentate line that appeared to be prolapsing mucosa. There was no evidence of arterial bleeding or mass. Cautery was used for hemostasis of the bleeding. There was no bleeding upon cessation of the procedure.
 

lcolborn

Networker
Messages
56
Best answers
0
~ and so, it's above the dentate line ......, 46614 is more appropriate versus the 45990. Just a reminder , I'm sure you already know, whenever there is a control of bleeding , your dx should be with bleeding etc.
 
Top