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excisional biopsy of perianal nodule under anesthesia

  1. #1
    Default excisional biopsy of perianal nodule under anesthesia
    Medical Coding Books
    We have been trying to find the right code for the following procedure. If anyone can help with this, it would be greatly appreciated.

    The op note says:

    She was brought to the operating room and general endotracheal anesthesia was induced. She was placed in the high lithotomy with SCDs in place and appropriate padding. The area was prepped and draped in the usual fashion and atibiotics were given. The time out was performed. An elliptical incision was made about this nodule with the intent o excise an ellipse of overlying skin as well. This was passed off the field as specimen without entering into the cyst at all. The superior margin of the lesion was tagged with a suture. I palpated this lesion after it was passed off the field actually grossly consistent with the cyst but we sent it to pathology as per routine. Hemostasis was achieved of the area with the aid of the cautery, The area was copiously irrigated. The deep dermal space was closed using interrupted 3-0 vicryl suture and the skin was closed using a running 4-0 Monocryl suture. Dermabond was applied. A thorough anal rectal exam was also given. The patient was awoken from anesthesia and goes to the recovery room in stable condition. All sponge, needle and instrument counts were correct at the end of case.


    With this procedure, I wonder if the unlisted 46999 is the right code. But, at the same time, 11422 includes the biopsy with the excision.

    Any input would be great. Thanks.

  2. #2
    St. Louis, Missouri
    I would look under excision of benign/malignant (depending on the path report) lesion of the trunk. 45990 for the anorectal exam.

    Melissa Blow, CPC

  3. #3
    Thanks for the response. I sent in the claim with the 11422. That does seem like the most accurate to the procedure.

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