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Thread: need HELP with CPTs

  1. #1

    Default need HELP with CPTs

    AAPC: Back to School
    Need help with CPTs. Thanks in advance.

    procedure: 1. transanal excision of anal/rectal neoplasm with primary closure.
    2. Excisional biopsy of polypoid vaginal lesion.

    op note: The villous polypoid structure was identified and extended from the right lateral to posterior midline area. The lesion was grasped at its right margin which was also slightly more proximal than the left/posterior midline area and a 3-0 chromic suture was placed in the grossly normal mucosa just proximal to lesion. Electrocautery was then used to excise the full thickness of the anoderm over the internal sphincter in the more distal posterior rectal portion of the lesion. The lesion was excised intact in its entirety and marked with a single short suture at the proximal/right margin and a double long suture in the distal/left margin. This was passed off the field for pathology.
    During patient's operation multiple indurated appearing vaginal polypoid lesions were noted. Gloves and gowns were changed, and the mucuosa beneath one of these lesions was numbed with 1 mL of 1% lidocaine with epinephrine and the lesion was sharply excised with Metzenbaum scissors and passed off the field for permanent pathology.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default NOT my area of expertise, But ...

    Not my area of expertise ... but ...

    Look at 46922 and 57135 and see if they match your documentation.

    F Tessa Bartels, CPC, CEMC

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