help with coding excision of anal fistual

Mklaubauf

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Hi, I need help coding this.
Here is the operative report:
Procedures:
1. Excision of indurated mouth of anal fistual with associated phlegmonous mass and fistulotomy.
2. Lateral internal subcutaneous sphincterotomy.

Procedural Note:
The patient was taken to the operating rrom after obtaining informed consent. He was placed under general anesthetic and then repositioned jackknife prone with the buttocks taped apart. The patient has an indurated mass just under the skin subcutaneous 2 to 3 cm from the anal verge at the 7:00 location. There was no obvious tract nor could I express any drainage whereas in the office yesterday I could express some drainge. I excisied the indurated mouth and an underlying associated mass that did not seem to have a deeper tract. That is to say I did not appreciate a core of fibrous tissue running deep.

Prior to this I did perform a rectal examination under anesthesia including the close inspection of the anal canal and the appropriate quadrants utilizing a bivalve retractor. There was an obvious fistulous opening in the anterior midline at the 6:00 location but I could not establish an obvious continuity with the inflammatory mass. After excision of the mass, as addressed in the first paragraph, there did seem to be a superficial communication with the midline opening at 6:00, which I did expose by dividing on top of the fistual probe with cautery. This resulted in a curved incision. I did approximate the skin with 3-0 chromic sutures at the distal most extent to decrease the size of the wound. I performed a lateral internal subcutaneous sphincterotomy. This allowed some relaxation of the sphincter. Triple antibiotic ointment and petroleum gauze dressing was place and a gauze overdressing.


I'm thinking 46270 which includes the sphincterotmy, but I don't know about the indurated mass.

Any help is greatly appreciated.
Marci
 
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This sounds like 46060 to me but he doesn't really describe it that way. He describes 46270 but this doesn't address the abscess. 46040 addresses the abscess. 46080 should get the sphincterotomy.

Really I bet this is 46270 but he describes the fistula as superficial so you can't use this one. Probably going to get dinged by the CCI edits. Hope this helps
 

Mklaubauf

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I can't bill both 46040 and 46080 together can I ? 46080 has a separate procedure listed.

I would not be able to put 59 I don't think.

Thank you all for the help on this.
Marci
 
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