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45171 / need help

  1. #1
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    Default 45171 / need help
    Medical Coding Books
    This was booked a a fistula, but no fistula found , but a benign polyp was found , should this be 45171 -excision of rectal tumor ?any suggestions please let me know

    PREOPERATIVE DIAGNOSIS: Possible perianal fistula.

    POSTOPERATIVE DIAGNOSIS: Left distal rectal mass.

    PROCEDURES PERFORMED: Examination under anesthesia and biopsy of left distal rectal mass.

    ANESTHESIOLOGIST:

    ESTIMATED BLOOD LOSS: Minimal.

    CLINICAL HISTORY: This is a 62-year-old who was about a month after sigmoidectomy for a colovesicular fistula, has complaint of daily perianal discharge, which had been present before surgery retrospectively. On exam, the patient appeared that she may have the external opening of a fistula. She is consented for exam, possible fistulotomy. On exam in the preoperative holding area, the patient had significant amount of stool smeared around her anus. There was nothing coming from her vagina. Physical exam of her vagina intraoperatively revealed no wall masses and no discharge from the vagina.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a prone Jackknife position. The perianal region was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine was injected as a local anesthesia. The anus was gently dilated up to three fingerbreadths. On external inspection, there were no abnormalities. Hill Ferguson retractor was inserted into the anus. There were some minimal internal hemorrhoids. The mucosa was pink and healthy circumferentially. There was no sign of a fistula on external or internal exam. There was a 1 x 0.5 cm benign-appearing polyp of the left distal rectum just proximal to the anal verge. This was excised and sent for specimen. Hemostasis was achieved easily with electrocautery. No other abnormalities were identified despite an extensive search. The patient had not been bowel prepped. There was some proximal pasty stool and rigid proctoscopy to examine the anastomosis would not be possible. The patient tolerated the procedure well.

  2. Default Muscle or just tissue?
    You need to know if the polyp/tumor consisted of muscle or was just tissue. Second, you need to know was it a partial thickness or full thickness excision. Once you determine those two items you'll be able to properly pick your CPT-4 code. Hope that helps.

  3. #3
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    NEW ORLEANS
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    Default
    all path showed was fibroepithelial polyp of skin-no sutures so guess cant use 45171
    Last edited by codedog; 08-04-2011 at 11:24 AM.

  4. #4
    Location
    NEW ORLEANS
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    Default
    Correct if I am wrong but I dont think there is enough info in this operative report-doc also stated he did an EUA- EXAM UNDER GENERAL ANESTHESIA- 45990 /,will I be able to use that . Problem I have is it came back a fibroepithelial polyp but I dont see codes for excision of polyps ,they have them but are under colonoscopy, anoscopy,proctosigmoidoscopy, which I dont see these choices in report- Am I missing something here?

  5. #5
    Default
    46606 is what I would use

  6. #6
    Location
    NEW ORLEANS
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    Default
    colorectal why 46606?.i dont see an anoscope in this one

  7. #7
    Default
    Hill Ferguson is an anoscope

  8. #8
    Location
    NEW ORLEANS
    Posts
    956
    Default
    ohh, thanks , I am glad to know that, thank you very much

  9. #9
    Default
    did he excise the entire polyp or for code 46606 it is just tissue samples. I think you need more detailed info. my 2 cents
    LG CPC,CASCC

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