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Need help with op note - posterior portion

  1. #1
    Default Need help with op note - posterior portion
    Medical Coding Books
    .DX - 1)Thrombosed external hemorrhoid 2) Excision of anal lesion
    Operation :Complete external hemorrhoidectomy. 2) Excision of anal lesion

    Findings : A 1.5 cm pedunculated , ulcerated lesion at right posterior portion of anal canal coompletely excised. 2) Thrombosed external hemorrhoids at 6 0'clock postion.


    After induction with general anestesia, the patient was placed in lithotomy postion, and the perneal area was prepped . Digital rectal exam revealed no obvious lesions. Anocopy was then performed to approximately 8 to 19 cm . Circumferential visual of the rectal vault mucosa reveal no lesions. Within the anal canal , there was a 1.5 cm ulcerated lesion with approximately 21.5 cm stalk emanating from the anal canal, chronically prolapse. This was elliptically incised and its base fulgurated. This was on the posterior side at approximately the 7 0'clock postion facing the patient. At the 6 0'clock posteriorly, there was an acutely thrombosed external hemorrhoid. This was elliptically with cautery, and clsed with a running 4-0 suture.

    Now I am loking at cpt code 46320 , because cpt coode reads excision of thrombosed hemorrhoid, external, but diuring doc also states in the operation paet that he did a complete external hemorrhoidectomy , which I want code 46250-dont feel thats right,
    also excsion of anal lesion ????? , not sure
    any suggestions -thanks

  2. #2
    I just did one kind of similar to this. The anal leasion was also a pedunculated anal mass. We ended up using the 46922 for that but it all depends on how the lesion was removed, I guess. For the hemorrhoidectomy, the 46320 looks good to me and seems to match his description of what was done.

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