Surgeon wants to bill 46060 for I&D perirectal abscess w/placement of seton. He is not doing any fistulectomy or fistulotomy. Since he wasnt doing the total parts of the code I have been adding mod-52. Or should this be billed as something else.
The patient was brought back to the operating room, placed in the supine position. General endotracheal anesthesia was performed. A time-out was
performed, identifying the patient and the procedure to be performed. Patient was placed in prone jackknife position. Perineum was prepped and draped in the usual sterile fashion. 1% lidocaine with epinephrine was used for local block. I first evaluated the gluteal wound. Patient had a large wound with large flaps. There was one area that was deep that traveled parallel to the rectum. I did open this up and there was some stool and purulence. I did perform a digital rectal exam which revealed a very stenotic and almost circumferential scarring. Patient also had an opening in the left posterior lateral region. I placed in a probe and this went straight into the anal canal. An anal fistula seton was placed. I then placed a probe through the opening in the gluteal wound which was in the right anterior lateral position. I was able to find an opening in the anal canal and placed an anal fistula seton. After placing the setons I did copiously irrigated out the area. I did close the gluteal wounds with Michael. I did have to undermine some of these so they would come together and come across while healing flat. Patient tolerated the procedure well and was brought to the recovery room in stable vacation. Lap and instruments were correct ×2.
So from this he did do a fistulotomy but the codes he is trying to use aren't for a perirectal abscess and that is what he is documenting. These are very hard to tell exactly where and provider needs to document it as the perirectal, perianal, ishio-- intramural, etc or you will never know. I am not sure what the "Wound" is referring to. I still say 46040, 46020-51.
But you could look at 46270 range also. Some providers don't know cpt differentiates between all those areas for abscess and if you show them that they will say it's this one but then they need to make sure their note reflects that. Hope that helps.