This is MEDICARE PATIENT , BOOKING WAS 45990 WITH DX AS 787.99. I think the code should be 45171 with a dx of 211.4 - path report came back as a tubular adenoma. Cpt code 45171 is the closest code I was able to find. Would these be bundled ? No sure,and would 45171 be a good choice ?
POSTOPERATIVE DIAGNOSIS: Anal mass.
OPERATION: Excision of anal mass.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table and underwent general anesthesia with successful endotracheal intubation. With the patient in lithotomy, the area was prepped and draped in the normal fashion. Rectal exam revealed an area coming from his posterior anoderm which was hard tell what it was. The entire area for around 2 to 3 cm was excised all the way to the external anal skin also. No muscle was gotten into. The entire area removed was around 3 to 4 cm. The area was sent to Pathology for permanent section. The mucosa of the anus was brought back to the anal skin with 3-0 Vicryl. A caudal block was then done with Marcaine with epinephrine. Again, no muscles were gotten into at all. A piece of Gelfoam was left for postoperative analgesia also and for hemostasis. Excellent hemostasis was noted to be obtained. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
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