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help with this operative report

  1. #1
    Location
    NEW ORLEANS
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    954
    Default help with this operative report
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    diagnosis (-1-) external skin tag (2)anal canal polyps (3) external perianal skin irritation

    PROCEDURE - Anal rectal examaination under anesthesia with excsion of anal canal polyps x2 and excision of skin tag

    Procedure:

    inspection of anal area demonstrated evidence of chronic skin irritation and inflammation . The anal canal was digitally examined and was somewhat rigid from chronic disease. The anoscope was gently inserted and circumferential inspection carried out . The patient had two polyps within the anal canal. One had a hemorrhoidal type apperance in the anterior quaderant and a secound polyp was an elongated simple mucosal polyp. Both of there were excised with the hormonic scalpel and submitted to pathology . An external skin tag was in the posterior quaderant and was excised with hormonic scapel. A hemostatic splint of gelfoam was then inserted into the anal canal and left in position.

    Would cpt code 46220 be a good choicefor eexcision of tag ,and I amnot sure about the polyps -ANY IDEAS -THANKS -
    Last edited by codedog; 10-28-2010 at 11:13 AM.

  2. #2
    Location
    NEW ORLEANS
    Posts
    954
    Default
    should i just use anal rectal exam ?

  3. #3
    Location
    Fayetteville, NC
    Posts
    300
    Default
    What about 46610 you did say he did an anoscopy right?
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  4. #4
    Location
    NEW ORLEANS
    Posts
    954
    Default
    welli wasgoing but it said he excised it with a scapel

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