tholcomb
Networker
Hello Coders, I have a question for the operative note below the cpt codes 46280, 46040, and 45300 per CCI edits these codes does not permit modifiers any suggestions would be greatly appreciated.
Thank you,
TH
OPERATIVE FINDINGS: *
The patient was found to have a large abscess cavity to the left of the rectum with loculations.
The rectal mucosa was markedly and acutely inflamed.
He an extrasphincteric fistula with internal opening superior to the dentate line and on the left and anterior on the rectal wall. The external opening opened into the abscess cavity.
*
TECHNIQUE: *
The patient was brought to the operating room, and after the induction of *
general anesthesia, he was placed in the lithotomy position upon the *
operating table. His buttocks were taped apart and the area was prepped and *
draped in the usual manner. Digital rectal exam was performed followed by a rigid proctoscopy.
The rectum was markedly inflamed and bled easily. He had a fistula opening on the anterior left rectal wall a few centimeters superior to the dentate line.
The proctoscope was withdrawn. The skin overlying the abscess to the left of the anus was injected with local anesthetic and an incision was made to the left of the anus from perineum to posterior to the anus to open the entire underlying cavity.
Loculations were broken up and the abscess tracked superiorly to the levators. A fistulotomy was performed down to the level of the sphincter muscle. The muscle was not divided. A vascular loop was passed through the remaining fistula tract into the rectum and then tied as a fibrosing seton. The wound was packed with a saline moisted Kerlex dressing and an ABD dressing was applied. All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated, and brought to the recovery room, awake and in stable condition.
Thank you,
TH
OPERATIVE FINDINGS: *
The patient was found to have a large abscess cavity to the left of the rectum with loculations.
The rectal mucosa was markedly and acutely inflamed.
He an extrasphincteric fistula with internal opening superior to the dentate line and on the left and anterior on the rectal wall. The external opening opened into the abscess cavity.
*
TECHNIQUE: *
The patient was brought to the operating room, and after the induction of *
general anesthesia, he was placed in the lithotomy position upon the *
operating table. His buttocks were taped apart and the area was prepped and *
draped in the usual manner. Digital rectal exam was performed followed by a rigid proctoscopy.
The rectum was markedly inflamed and bled easily. He had a fistula opening on the anterior left rectal wall a few centimeters superior to the dentate line.
The proctoscope was withdrawn. The skin overlying the abscess to the left of the anus was injected with local anesthetic and an incision was made to the left of the anus from perineum to posterior to the anus to open the entire underlying cavity.
Loculations were broken up and the abscess tracked superiorly to the levators. A fistulotomy was performed down to the level of the sphincter muscle. The muscle was not divided. A vascular loop was passed through the remaining fistula tract into the rectum and then tied as a fibrosing seton. The wound was packed with a saline moisted Kerlex dressing and an ABD dressing was applied. All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated, and brought to the recovery room, awake and in stable condition.