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rectal biopsy with

  1. #1
    Default rectal biopsy with
    Medical Coding Books
    Patient had a rectal biopsy , examination under anesthia and hemorrhoidectomy , hemmorrhoid was internal , So it it ok yo code all three procedures?

  2. Default
    ...I think the 'exam under anesthesia' would be considered integral to the rectal biopsy and/or the hemorrhoidectomy so I wouldn't code separately for that. Just a thought.

  3. #3
    I would only code the internal hemorrhoidectomy anything is included.

  4. #4
    ok here is report -so just code for internal hemorrhoidectomy 46255

    POSTOPERATIVE DIAGNOSIS: Rectal pain status post hemorrhoid banding.

    PROCEDURES PERFORMED: Examination under anesthesia, rectal biopsy, and hemorrhoidectomy.

    CLINICAL HISTORY: An 80-year-old female with persistent perianal pain after hemorrhoid banding. I am uncertain of the etiology.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in the lithotomy position. The perianal region was prepped and draped in a sterile fashion. The anus was gently dilated up to three fingerbreadths. 10 cc of 0.25% Marcaine with epinephrine were injected around the anus for a block. The Hill-Ferguson retractor was inserted into the anus. The mucosa was pink and healthy circumferentially. A biopsy was taken near the dentate line on the patient's right lateral. Hemostasis was achieved with electrocautery. There was no sign of a fissure. There was no fistula. Everything appeared to be healing well after her pre hemorrhoid banding. There was no residual scarring or stenosis. There was a significant internal hemorrhoid column on the patient's right posteriorly. This could be causing the patient's discomfort. No significant other abnormalities were identified. Decision was made to excise this. A 3-0 chromic suture was placed at its apex. An elliptical incision was made. Next, the hemorrhoid was dissected free of the surrounding tissue with sharp dissection staying anterior to the internal anal sphincter muscle. Hemostasis was achieved with running 3-0 chromic running from the apex stitch to the external anal area. Hemostasis was complete and the mucosa was re-approximated. A piece of Gelfoam was placed within the anus. The former biopsy site was inspected first. There was no bleeding noted. The patient tolerated the procedure well.

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