Excision Abscess/Anoscopy


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I am not sure if I should bill the anoscopy, I believe this is included, I am not sure if he did a anoscopy from reading the report. Is a bivalved speculum part of the scope? The information I read on it says it is a tube inserted for diagnostic purposes. iIthink I should just code the excision.:cool:

The following report reads:
A Bivalved speculum was inserted. There was no sign of an internal fistula tract. There was no significant perianal disease. This appeared to represent a primary abscess involving the right buttock. An ellipitical incision was used to excise the abscess of the right buttock. dissection was carried down to the subq tissues. There was no sign of a fistula tract on dissection of this. The specimen was removed, and submitted for histopathology. The abscess measured 2.3cm. The skin incision measured 3.2cm. At the completion of the PX, all sponge, needle and instrument counts were correct.

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Excision Abscess

Bivalve is Aspeculum with two opposed blades that can be separted or closed. It is an instrument for examination fo canals or hollow organs, what they use on woman when examination of the Vagina Canal. So I read nothing in the Op Report about using a Anscopy. I would just code Excison of Abscess.

Kimberly CPC