I would love thoughts on this case. These are the codes billed.
45330 59

Dx codes 46080, 455.0 and 565.0

46080 is a higher rvu and under this code it does not say 45330 is bundled.
45330 is a lower rvu but does state 46080 is included.

Insurance has paid 45330 and denied 46080. I sent the op report with the denial and 46080 is still denying.

I feel the op report clearly showing this being a separate procedure. Do you feel the insurance is correct and I should appeal this by letter?
Thank you in advance for any help!!!!

Preoperative diagnosis: Anal pain and bleeding suspected fissure and
residual small external hemorrhoid.
Postoperative diagnoses:
1. Irritated rectum secondary to Fleet's prep versus chronic irritation.
2. Posterior anal tags/polyp and residual small posterior hemorrhoid,
3. Minor posterior anal fissure with internal sphincter spasm.

1. Excision of posterior anal tag and residual external hemorrhoid
2. Internal sphincterotomy.
3. Flexible sigmoidoscopy.

Patient tolerated procedure well.

Estimated blood loss less than 50 mL.

Indications for procedure: Please history and physical as this outlines it

Description of procedure: The patient was placed in supine position on the
operating room table and after induction of adequate general anesthesia via
LMA by Dr. N we placed the patient into lithotomy position and a
flexible sigmoidoscopy was performed. Using a flexible colonoscope first
lubricated the scope I then did a rectal examination which revealed a
palpable previously known posterior anal tag or polyp and no other palpable
abnormalities. The scope was then entered the anal opening and we went
ahead and advanced this under direct vision to about 85 cm. There were some
significant curves in the sigmoid but we are able to negotiate this without
too much problems. We first saw some stool at about 85 cm. The scope was
then carefully withdrawn examining all surfaces. The portion of the
descending colon seen appeared fairly normal a portion of the sigmoid colon
seen as we passed through appears to be healthy. There was perhaps a very
minor diverticulum in one or two places. There was mucus throughout the
area but was otherwise unremarkable. In the actual rectum itself there was
evidence of irritation. Whether this was from the Fleet's prep or whether
there was a chronic low-grade irritation of the lining with some friable
mucosa was difficult to tell. There were some small punctate areas of
abrasion possibly from placing the scope originally before we could see
well. There were no polyps identified. Just before the exit one could see
the round whitish scar from the previous hemorrhoidopexy and there were no
enlarged internal hemorrhoids noted. As we were seeing this we were also
seeing posteriorly the anal polyp or tag that had been palpated previously.
Scope was withdrawn and passed off the field and we proceeded with the
other part of the procedure.

Following this we carefully placed the patient more balanced into a
Trendelenburg position and left her in the lithotomy then carefully placed
the anal retractors and carefully inspected. The small anal retractor did
not track the buttocks enough to be able to see well therefore we used the
clamshell rectal retractor and spread this a little bit. Completely
examining the circumference of the anal opening there was no of the skin
breakdown except posteriorly right at the base of the polyp there was a
slight crack in the mucosa and like a standard fissure but certainly a
small opening. There was some irritation present and some scar tissue
otherwise no changes there was no fissure anywhere else in the
circumference of the anal area. Following this with the clamshell present
and being studied I carefully excised the residual external hemorrhoid and
polyp with a 15 blade knife achieved hemostasis with this along the exposed
tissues beneath the mucosa passed this off the field. We could palpate
internal sphincter muscle posteriorly then in this open wound and a 15
blade knife was used to divide the fibers gently until this released the
tension on the retractor that was holding this area open and that seemed to
release nicely. Once hemostasis appeared to be good I then closed the
mucosa over the area starting high and tying off the pedicle of the base of
the external hemorrhoid with 3-0 Vicryl and running this out approximating
the mucosa meticulous all the way out to the anal skin and tying this on
the external anal skin. Hemostasis was achieved by placing one more
figure-of-eight Vicryl suture high along the start of this running suture
line and it was tied and there was no further bleeding identified. We
carefully cleansed the area and a piece of rolled Gelfoam with bacitracin
on it was placed in the anal opening as a pack and the patient was taken to
the recovery room in good condition. A pad will be applied and she will be
asked to use Sitz baths starting tomorrow.