Rectal packing


True Blue
The Woodlands, TX
Best answers
I can't seem to find a code to match what my doc is doing and being fairly new to General Surgery coding, I could use some guidance.

Op Note:

Once properly anesthetized, patient was prepped and draped in usual sterile fashion. The patient was placed in the lithotomy position, and the rectum was inspected by placing a speculum into the rectal vault. The mucosa was extremely friable. Gross blood was encountered. The was evacuated with suction but no definitive pustule lesion was seen. Some ulcerated lesions that we oozing were cauterized. The hartmann's pouch extended up further. The was opened and inspected, and there appeared to be some active bleeding from this area, but I was unable to visualize any lesion that could be treated. Therefore, the entire Heartmann's pouch was packed with 2 rolls of Gelfoam that has been soaked with thrombin, the first was consisted of 3 large sheets of Gelfoam. The 2nd roll consisted of 2 large sheets, and then the outer part of the rectum was packed with a lap sponge. Packing left in place. Patient take to recovery room.

I can't use 12021 or 45005, I don't believe. Should I use the unlisted code, 45999?

Any responses are appreciated!! Even better if you can provide resources.

Interesting.... Sounds like 46614, but unfortunately a scope is used, not a speculum! That's the only procedure I know of that comes close. :(