Hello everyone,
I am new to GI surgery. I need help coding this procedure below. I'm having a hard time what bundles into each other. I came up with CPT codes 46020,46924 and 11100.
PREOPERATIVE DIAGNOSIS:
1. Anal mass.
2. Anal fistula.
POSTOPERATIVE DIAGNOSIS:
1. Anal mass.
2. Anal fistula.
3. Anal condylomata.
PROCEDURE PERFORMED:
1. Exam under anesthesia.
2. Placement of Seton.
3. Destruction of anal condylomata.
4. Biopsy of anal mass.
INDICATIONS FOR PROCEDURE:
This is a 37-year-old man who was admitted in a state of sepsis and was found
to have multiple foci of infection including a right septic hip for which he
underwent a washout on 11/26/2016. At the time that he was admitted, had
also endorsed a several month history of anal drainage. I was able to take a
look at his anus at the time of his hip washout on Saturday and appeared that
he had a mass and fistula on a cursory exam. However, the orthopedic OR did
not have adequate instruments for me to perform a procedure, so he was brought
back to the operating room today for a better exam under anesthesia and a the
following procedure. Of note, he also came in with a new diagnosis of HIV with
a high viral load, CD4 count is pending.
PROCEDURE:
The patient was greeted in the preoperative area. I outlined the consent with
him including the steps of the procedure, as well as associated risks and
benefits. The risks namely included injury to the sphincter with fecal
incontinence, persistence of fistula, recurrence of abscess, bleeding, and the
possibility that this mass was a malignancy. He was aware of these risks and
decided to proceed. He was brought back to the operating room.
An anesthesia timeout was performed, outlining relevant details of the case.
He was due for Zosyn as per his floor orders and so that was administered. He
had Pneumoboots placed on his legs and they were working. He was induced in
his bed in the usual manner and then flipped prone for the procedure, being
mindful to protect his genitalia, nipples, and all pressure points. The bed
was positioned in prone jackknife. The buttocks were taped apart to allow for
adequate exposure. The perineum was prepped with Betadine and draped in the
usual fashion. At that time, a surgical timeout was performed in which all
relevant details of the case were outlined. All members of care team were
present and agreed to proceed. The procedure began with a digital rectal exam
which was revealing of multiple subcentimeter mucosal irregularities, as well
as a firm posterior anal mass. There was on the internal side some dimpling of
the anal mucosa overlying this palpable mass. Upon palpation of the mass,
there was some mucopurulent fluid extruded from an external opening that was
evident within a prominence of mass-like condylomatous tissue. The Hill
Ferguson was introduced into the anal canal to get a better look at this area
of dimpling. A fistula probe was inserted into the external opening within a
mound of abnormal-appearing condylomatous tissue. This fell very easily into a
space that extended to the right perianal tissue and also fell directly into
an internal opening in the posterior midline suggestingthat he has a posterior
midline fistula with extension of the abscess cavity into the R lateral
ischioanal tissue. A vessel loop was used to create a Seton within this
posterior anal fistula in the standard fashion. The condylomatous very firm
tissue was excised superficially and sent off for pathology. In addition,
curettings of the fistulous tract, which appeared to go through this palpable
mass were also obtained and included in that specimen labeled anal mass.
Attention was then turned to the perianal skin, which was revealing of a
number of subcentimeter condylomatous lesions. A smoke-evac was set up and
these lesions were biopsied and sent off for pathology and labeled as anal
warts. The remainder of the visible lesions were also fulgurated. The Hill
Ferguson was then inserted back into the anal canal and all four quadrants
were inspected closely for anal canal condyloma and those were fulgurated as
identified. This concluded the case. Polymyxin antibiotic ointment was placed
over the anus and dressed with 4 x 4 fluffs.
All counts were correct x2.
I attest to being present and scrubbed for the entirety of the case.
I am new to GI surgery. I need help coding this procedure below. I'm having a hard time what bundles into each other. I came up with CPT codes 46020,46924 and 11100.
PREOPERATIVE DIAGNOSIS:
1. Anal mass.
2. Anal fistula.
POSTOPERATIVE DIAGNOSIS:
1. Anal mass.
2. Anal fistula.
3. Anal condylomata.
PROCEDURE PERFORMED:
1. Exam under anesthesia.
2. Placement of Seton.
3. Destruction of anal condylomata.
4. Biopsy of anal mass.
INDICATIONS FOR PROCEDURE:
This is a 37-year-old man who was admitted in a state of sepsis and was found
to have multiple foci of infection including a right septic hip for which he
underwent a washout on 11/26/2016. At the time that he was admitted, had
also endorsed a several month history of anal drainage. I was able to take a
look at his anus at the time of his hip washout on Saturday and appeared that
he had a mass and fistula on a cursory exam. However, the orthopedic OR did
not have adequate instruments for me to perform a procedure, so he was brought
back to the operating room today for a better exam under anesthesia and a the
following procedure. Of note, he also came in with a new diagnosis of HIV with
a high viral load, CD4 count is pending.
PROCEDURE:
The patient was greeted in the preoperative area. I outlined the consent with
him including the steps of the procedure, as well as associated risks and
benefits. The risks namely included injury to the sphincter with fecal
incontinence, persistence of fistula, recurrence of abscess, bleeding, and the
possibility that this mass was a malignancy. He was aware of these risks and
decided to proceed. He was brought back to the operating room.
An anesthesia timeout was performed, outlining relevant details of the case.
He was due for Zosyn as per his floor orders and so that was administered. He
had Pneumoboots placed on his legs and they were working. He was induced in
his bed in the usual manner and then flipped prone for the procedure, being
mindful to protect his genitalia, nipples, and all pressure points. The bed
was positioned in prone jackknife. The buttocks were taped apart to allow for
adequate exposure. The perineum was prepped with Betadine and draped in the
usual fashion. At that time, a surgical timeout was performed in which all
relevant details of the case were outlined. All members of care team were
present and agreed to proceed. The procedure began with a digital rectal exam
which was revealing of multiple subcentimeter mucosal irregularities, as well
as a firm posterior anal mass. There was on the internal side some dimpling of
the anal mucosa overlying this palpable mass. Upon palpation of the mass,
there was some mucopurulent fluid extruded from an external opening that was
evident within a prominence of mass-like condylomatous tissue. The Hill
Ferguson was introduced into the anal canal to get a better look at this area
of dimpling. A fistula probe was inserted into the external opening within a
mound of abnormal-appearing condylomatous tissue. This fell very easily into a
space that extended to the right perianal tissue and also fell directly into
an internal opening in the posterior midline suggestingthat he has a posterior
midline fistula with extension of the abscess cavity into the R lateral
ischioanal tissue. A vessel loop was used to create a Seton within this
posterior anal fistula in the standard fashion. The condylomatous very firm
tissue was excised superficially and sent off for pathology. In addition,
curettings of the fistulous tract, which appeared to go through this palpable
mass were also obtained and included in that specimen labeled anal mass.
Attention was then turned to the perianal skin, which was revealing of a
number of subcentimeter condylomatous lesions. A smoke-evac was set up and
these lesions were biopsied and sent off for pathology and labeled as anal
warts. The remainder of the visible lesions were also fulgurated. The Hill
Ferguson was then inserted back into the anal canal and all four quadrants
were inspected closely for anal canal condyloma and those were fulgurated as
identified. This concluded the case. Polymyxin antibiotic ointment was placed
over the anus and dressed with 4 x 4 fluffs.
All counts were correct x2.
I attest to being present and scrubbed for the entirety of the case.