drhoads
Guru
Procedure: Squamous lesion of the rectum and anal fissure
Upon inspection of the anus, there was a squamous lesion coming off at the 7 o'clock and 8 o'clock position with two slit like fissures each about 1cm long x about 6mm width involved in either side of squamous lesion. As such, an elliptical excision was traced with a #15 blade, which started at the mucosal lesion at the anal verge and pyramidal or diamond-shaped excisional area was excised using a #15 blade initially to excised the squamous lesion and these two fissures, then electrocautery was sued to dissect this squamous lesion off the underlying spincter and subcutanewous tissue. Once completely off, bleeding points were controlled with electrocautery and than a running 2-0 Monocryl was used to reapproximate the mucosa and epidermal layer. Interrupted stitches of 2-0 Monocryl were also placed for reinforcement. Examination under anesthesia revealed minimal hemorrhoidal disease internally. No evidence of fistula or intraanal mass or mucosal polyps. There was a small fissure off to the right at the 3 o'clock position, which I left as the sphincter appeared to be patulous and was not tight.
Would I use codes this from the Integ. section 116XX in addition to intermediate repair 120XX ?
Upon inspection of the anus, there was a squamous lesion coming off at the 7 o'clock and 8 o'clock position with two slit like fissures each about 1cm long x about 6mm width involved in either side of squamous lesion. As such, an elliptical excision was traced with a #15 blade, which started at the mucosal lesion at the anal verge and pyramidal or diamond-shaped excisional area was excised using a #15 blade initially to excised the squamous lesion and these two fissures, then electrocautery was sued to dissect this squamous lesion off the underlying spincter and subcutanewous tissue. Once completely off, bleeding points were controlled with electrocautery and than a running 2-0 Monocryl was used to reapproximate the mucosa and epidermal layer. Interrupted stitches of 2-0 Monocryl were also placed for reinforcement. Examination under anesthesia revealed minimal hemorrhoidal disease internally. No evidence of fistula or intraanal mass or mucosal polyps. There was a small fissure off to the right at the 3 o'clock position, which I left as the sphincter appeared to be patulous and was not tight.
Would I use codes this from the Integ. section 116XX in addition to intermediate repair 120XX ?