lindsey.hansen
Networker
Hey can someone help me - I am planning on using the anal unlisted code 46999 but I can't come up with a like code to save my life.
A careful inspection of the anus and anoderm showed no external
abnormalities . Digital rectal examination revealed a slightly
stenotic coloanal anastomosis at approximately 2 .5 cm cephalad to the
anal verge . There was a slight palpable defect in the right
posterolateral aspect . No other abnormalities were noted. Anoscopy
confirmed a 2 to 3 mm opening in the left posterolateral quadrant of
the coloanal anastomosis. I was able to pass the tips of a tonsil
clamp into this presacral space . There were no other abnormalities
noted . An Endo-GIA 30 nun 5tapling device wa5 5elected. A blue 5taple
cartridge was placed within the stapler, and then the stapler was
passed through the anus. One side of the stapler was passed in the
presacral space through the disruption. The other was left within the
lumen of the neorectum. I then closed the device and left it in this
closed position for approximately one minute . The device was then
fired . The stapler was then removed . I re-examined the area, both by
digital examination and by direct visualization , using a small sawyer
anoscope . The opening into the presacral space was now significantly
larger. The presacral space itself appeared very well epithelialized,
both by palpation and by direct visualization . I was surprised by how
little granulation tissue was noted. I then irrigated the surgical
site and checked for hemostasis. There was no evidence of active
hemorrhage. All devices were removed, and the patient appeared to
tolerate the procedure well. She was awakened in the operating room,
extubated, and transported to Recovery in stable condition.
A careful inspection of the anus and anoderm showed no external
abnormalities . Digital rectal examination revealed a slightly
stenotic coloanal anastomosis at approximately 2 .5 cm cephalad to the
anal verge . There was a slight palpable defect in the right
posterolateral aspect . No other abnormalities were noted. Anoscopy
confirmed a 2 to 3 mm opening in the left posterolateral quadrant of
the coloanal anastomosis. I was able to pass the tips of a tonsil
clamp into this presacral space . There were no other abnormalities
noted . An Endo-GIA 30 nun 5tapling device wa5 5elected. A blue 5taple
cartridge was placed within the stapler, and then the stapler was
passed through the anus. One side of the stapler was passed in the
presacral space through the disruption. The other was left within the
lumen of the neorectum. I then closed the device and left it in this
closed position for approximately one minute . The device was then
fired . The stapler was then removed . I re-examined the area, both by
digital examination and by direct visualization , using a small sawyer
anoscope . The opening into the presacral space was now significantly
larger. The presacral space itself appeared very well epithelialized,
both by palpation and by direct visualization . I was surprised by how
little granulation tissue was noted. I then irrigated the surgical
site and checked for hemostasis. There was no evidence of active
hemorrhage. All devices were removed, and the patient appeared to
tolerate the procedure well. She was awakened in the operating room,
extubated, and transported to Recovery in stable condition.