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Peri-anal mass excision

  1. #1
    Default Peri-anal mass excision
    Medical Coding Books
    I cannot for the life of me come up with a code that I feel comfortable with on this one, so any input is greatly appreciated.

    The op note says: " Externally at the 7 o'clock position, there is a thick induration and a small opening in the skin. When squeezed this area there was clear fluid extruded. It did not appear to be purulent at this time. No communication from the external opening to the internal side of the rectum was noted. Palpable thickened tissue with the overlying small opening extruding clear watery fluid was completely excised along with the overlying skin. Subcutaneious tissue there is thick and indurated tissue which appears to be chronic inflammation. No abscess cavity was noted. Complete excision of the involved tissue was done down to the perianal and _____ rectal fossa. Palpation ruled out any other abnormality in this area."

    Thanks for your help! :0)

  2. Default
    Quote Originally Posted by JenReyn99 View Post
    I cannot for the life of me come up with a code that I feel comfortable with on this one, so any input is greatly appreciated.

    The op note says: " Externally at the 7 o'clock position, there is a thick induration and a small opening in the skin. When squeezed this area there was clear fluid extruded. It did not appear to be purulent at this time. No communication from the external opening to the internal side of the rectum was noted. Palpable thickened tissue with the overlying small opening extruding clear watery fluid was completely excised along with the overlying skin. Subcutaneious tissue there is thick and indurated tissue which appears to be chronic inflammation. No abscess cavity was noted. Complete excision of the involved tissue was done down to the perianal and _____ rectal fossa. Palpation ruled out any other abnormality in this area."

    Thanks for your help! :0)
    I feel like going for these options but only as suggestion to ponder, not conclusive, with priority selection:
    1) 27048 - Excision of tumor(mass)pelvis and hip area: DEEP, subfacial, intramuscular. I lean more for this because: a) this is pelvic area b) anorectal or ischiorectal fossa is an area of deep soft tissues or even more than subfacial and anatomically a part(soft tissues) of pelvic area /region.
    2) Could this go for: 1142X series, so long we have not have the path report to prove otherwise?as malignant lesion. But wedo not have the measurement and it is not with specificity. This I am not happy with.

  3. #3
    Default
    haha, I had a similar op note that I had to put aside pending for path to make my decision. In my case was already a proven melanoma though.

  4. #4
    Default
    Quote Originally Posted by preserene View Post
    I feel like going for these options but only as suggestion to ponder, not conclusive, with priority selection:
    1) 27048 - Excision of tumor(mass)pelvis and hip area: DEEP, subfacial, intramuscular. I lean more for this because: a) this is pelvic area b) anorectal or ischiorectal fossa is an area of deep soft tissues or even more than subfacial and anatomically a part(soft tissues) of pelvic area /region.
    2) Could this go for: 1142X series, so long we have not have the path report to prove otherwise?as malignant lesion. But wedo not have the measurement and it is not with specificity. This I am not happy with.
    I would go with 27048 as well.

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default 46045
    Did you look at 46045 - The physician drains a perirectal abscess in the intramural, intramuscular, or submucosal position. The physician identifies the location of the abscess in relation to the sphincter muscles. The perianal skin or rectal mucosa over the abscess is incised. Dissection is carried through muscle if necessary and the abscess cavity is opened and drained. The incision is packed open for continued drainage.

    While your documentation is far from perfect, CPT 46040 would not include dissection below the subq tissues, so I think that is out.

    I do NOT agree with using 27048 .... you do not have anywhere near the required documentation for use of that code (which requires size of mass, by the way).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. Default
    I was also tempted to go for 4604X bu the description does not meet he procedure done.
    The code 27048 does not require size or extent by its description.
    I am convinced with the code 27048 than any other for this scenario and the surgeons documentation (op.notes). he has stated that "Complete excision of the involved tissue was done down to the perianal and _____ rectal fossa.) the gap is anorectal/ ischiorectal fossa.
    The anorecto or ischiorectal fossa is a prism like fossa /structure with its base directed to the surface of the perineum, and its apex at the line of meeting of the obturator and anal fasciae, with the boundaries anteriorly, laterally and posteriorly with many structures contained as follows:
    [ SUPERIOR:
    Levator ani
    INFERIOR:
    skin
    MEDIAL:
    Levator ani
    Sphincter ani externus muscle
    anal fascia

    POSTERIOR
    Gluteus maximus
    sacrotuberous ligament
    LATERAL
    tuberosity of the ischium
    Obturator internus muscle
    obturator fascia


    ANTERIOR
    fascia of Colles covering the Transversus perinei superficialis
    inferior fascia of the urogenital diaphragm



    The contents include:
    • Inside Alcock's canal, on the lateral wall
    o internal pudendal artery
    o internal pudendal vein
    o pudendal nerve
    • Outside Alcock's canal, crossing the space transversely
    o inferior rectal artery
    o inferior rectal veins
    o inferior anal nerves
    o fatty tissue across which numerous fibrous bands extend from side to side
    ]
    Last edited by preserene; 07-27-2011 at 09:22 PM.

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Not 27048
    I do NOT believe the documentation supports use of 27048. Following from Encoder Pro

    27048
    Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm
    The physician removes a tumor from the soft tissue of the pelvis and hip area that is located in the subcutaneous tissue in 27043 and 27047 and in the deep soft tissue, below the fascial plane, or within the muscle in 27045 and 27048. With the proper anesthesia administered, the physician makes an incision in the skin overlying the mass and dissects to the tumor. The extent of the tumor is identified and a dissection is undertaken all the way around the tumor. A portion of neighboring soft tissue may also be removed to ensure adequate removal of all tumor tissue. A drain may be inserted and the incision is repaired with layers of sutures, staples, or Steri-strips. Report 27047 for excision of a subcutaneous tumor whose resected area is less than 3 cm and 27043 for excision of a subcutaneous tumor 3 cm or greater. Report 27048 for excision of a subfascial or intramuscular tumor whose resected area is less than 5 cm and 27045 for excision of a subfascial or intramuscular tumor 5 cm or greater.

    NOTE: Size size of tumor is specified in the CPT code, your documentation must include size of the mass. The documentation doesn't have ANY indication of a tumor.

    ***************************

    Previous post with description of 46045 shows that dissection MAY extend into the muscle.

    I still believe 46045 is the best option. UNLESS, you want to use an Unlisted code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  8. #8
    Default
    I agree with Tessa. 46045.

    chronic inflammation to me indicates an abscess even though there was no abscess code.

    This is not a tumor!

  9. Default
    Well that is a good point.
    But IT WAS AN EXCISION OF MASS (as per the surgeon):
    When the surgeon excised a mass, he did not opt for placing a diagnosis “ abscess”. An abscess involves drainage of the pus/purulent material, and not ‘EXCISION'. Well, a chronic abscess when untreated, can produce damage to the tissues and in course of time can produce a fistula(e) which has an abnormal pathway into the surrounding areas and an excision of the whole fistula (fistulous tract) becomes mandatory. May be that is what happened here.
    But now, at the time of surgery it is a fistulous mass- that is what he excised. How could we give CODING MERIT for incision and DRAINAGE, WHILE IT IS AN EXCISION THAT WAS PERFORMED?
    I would like a validation for this please, it not bad, though.

    Another thing is I was going as per the 2009 CPT manual(where there is no size factor as description. Is there a size factor for the code 2704x in the latest manuals; please let me know
    to correct my ignorance.
    Thank you

  10. #10
    Location
    Milwaukee WI
    Posts
    4,466
    Default NO documentation to support 27048
    Preserene .... I beg to differ. The surgeon does not state exicision of mass.

    And you should really be using a 2011 book for accurate coding. Size of mass is a requirement throughout the book.

    I stick with CPT 46045.

    F Tessa Bartels, CPC, CEMC

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