mmayhand2018
New
This is the op report of the procedure that I'm coding. I wanted to use CPT code 46260, but wasn't sure if it could be used since there were two lesions excised externally and one internally. Please advise?
Digital rectal exam performed, noting lax anal tone under general anesthesia, noting no mass ,fissures, fistula. Then anoscope/speculum lubed and inserted to hub to about 10 cm and withdrew slowly and repeated to examine all four quadrants of anus. Noted complex 4:00 hemorrhoid of internal and external hemorrhoid reaching back, initially thought to be rectal prolapse however was isolated to the left posterior wall. There is a external hemorrhoid at 6 o'clock position. Before complex hemorrhoid was removed by ligating the apex with 2-0 Vicryl, then Thunderbeat vessel sealer was used to dissect and resect out the hemorrhoid tissue preserving the anal sphincter. The mucosal defect was then reapproximated with running 2-0 Vicryl. There was adequate hemostasis. Then external hemorrhoid was resected for physician skin closed partially with 2-0 Vicryl. Anal canal was able to widen to 2 finger dilation without narrowing. Anal packing with xeroform/gel foam tampon placed with silk string. Patient placed back in supine position and sedation weaned and extubated without complications
Digital rectal exam performed, noting lax anal tone under general anesthesia, noting no mass ,fissures, fistula. Then anoscope/speculum lubed and inserted to hub to about 10 cm and withdrew slowly and repeated to examine all four quadrants of anus. Noted complex 4:00 hemorrhoid of internal and external hemorrhoid reaching back, initially thought to be rectal prolapse however was isolated to the left posterior wall. There is a external hemorrhoid at 6 o'clock position. Before complex hemorrhoid was removed by ligating the apex with 2-0 Vicryl, then Thunderbeat vessel sealer was used to dissect and resect out the hemorrhoid tissue preserving the anal sphincter. The mucosal defect was then reapproximated with running 2-0 Vicryl. There was adequate hemostasis. Then external hemorrhoid was resected for physician skin closed partially with 2-0 Vicryl. Anal canal was able to widen to 2 finger dilation without narrowing. Anal packing with xeroform/gel foam tampon placed with silk string. Patient placed back in supine position and sedation weaned and extubated without complications