Wiki Help with op report - Pre and post op dx

[drhoads]

Pre and post op dx: External hemorrhoid

Procedure performed: Excision of external hemorrhoid

An IV was placed. She was given preoperative IV antibiotics, taken to surgery, placed under general anesthesia and then place in a a prone position. The large external hemorrhoid was identified. The anus was dilated, a rectal exam under anesthesia was preformed. NO other abnormalities were identified except for some other small external hemorrhoids. The large external hemorrhoid was then removed, excised with difficulty and the incision was closed with a running locking 3-0 Vicryl suture.

Path report: Squamous cell carcinoma

Not sure of code to use because of path report. Either CPT 46255 or 45171 ???

 

[Snflwr81]

If your doing professional physician coding you can't code from the path report. I would go with 46255.

 

[drhoads]

I understand and agree. Thanks so much!

 

[TWinsor]

I think you should use 46250. 46255 is internal and external hemorrhoids. You only have excision of external.