I have a question about the following dictation:
Post-op Dx: LEFT PERIRECTAL ABSCESS AND RECTAL FISTULA
Procedure: EXAMINATION UNDER ANESTHESIA AND SETON PLACEMENT
Technique: An adequate amount of general anesthesia was given and patient was placed in the prone jack-knifed position. Next, the buttocks were taped apart. Then, after that, on rectal exam, it was noted that there was some hardened induration towards the left side. An anal retractor was put into place and then with putting peroxide through the opening hole on the left buttock, it was noted to come through in through the left side of the rectum. Thus a probe was used to go through the fistula and then a silk was tied to this and brought through the opening up through the cavity. On to this was tied a vessel loop which was then brought through as well and this was loosely tied and stapled. Then the cavity was cleaned out using a curette. After that, the area was packed with 2 inch vaginal packing and covered with dry dressing. The patient tolerated the procedure well.
This was coded as:
46020 Placement of Seton
46020-51 Placement of Seton
45990-51 Anorectal exam, surgical, requiring anesthesia, diagnostic
As a newly hired coder, I was tasked to review recently coded procedures to become familiar with the surgical practice. After reviewing this dictation and the procedures coded, I do not believe 45990 can be coded with 46020, in addition, I would only have coded the 46020 once. However, the physician does use a curette to clean out the fistula cavity, which seems to me should be coded. After reading all the procedure lay descriptions I am still confused about what to bill, but am leaning toward:
46020 Placement of Seton
46045-51 Incision & drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia
or would it be more accurate with just:
46060 Incision & drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton
I would appreciate any insights on this subject. Thanks
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