Confused - do I just code placement of senton ?

codedog

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do I just code placement of senton ? not sure .


PREOPERATIVE DIAGNOSIS: Fistula in ano.

POSTOPERATIVE DIAGNOSIS: Fistula in ano.

PROCEDURE PERFORMED: Fistula partial opening and Seton placement.

PROCEDURE IN DETAIL: The patient was taken to the operating room after obtaining informed consent and placed on the operating table in a supine position. Following the achievement of adequate general endotracheal anesthesia, the patient's legs were placed in lithotomy position and the buttocks area was prepped with Betadine gel and sterilely draped.

The anal canal was examined with the operating anoscope and the posterior anal fistula was identified. A probe was used to enter the fistula from the external opening and identified the internal opening. This fistula was beneath the internal anal sphincter and for this reason partial cautery of the mucosa over the anal sphincter was followed by placement of a Seton. The Seton was tied with a silk suture and the patient will be seen in one week for tightening of the Seton. The patient tolerated the procedure well, was awakened from general anesthesia without complications, and transferred to the recovery room in satisfactory condition.
 
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