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Polp/tag from prolapsed rectum

  1. Default Polp/tag from prolapsed rectum
    Medical Coding Books
    I used anesthetic injected into the area using a little low strength Marcaine to anesthetize the area. The area was then exposed. I used a suture to attempt to try to
    tie the tag off, however, the material was exceedingly friable, however the tag was removed. I used both a disposable heat cautery as well as silver nitrate sticks to cauterize the area that was oozing. I then used Xeroform with a 4 x 4 to reduce the prolapsed rectum which reduced easily and packed with the Xeroform and 4 x 4s. The patient was then monitored. She remained stable for us. There was no more oozing from the rectum. I did send the specimen off for pathology. In addition, this was all done with the consent of the patient. She did receive a total of 100 mcg of fentanyl and 0.5 mg of Ativan during the procedure and tolerated this well.

    could I possibly use 45190? or would this have to be included in the E/M as no procedure code for this?
    thanks

  2. Default
    anyone have a suggestion?
    thanks

  3. #3
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    Default
    Quote Originally Posted by nabernhardt View Post
    I used anesthetic injected into the area using a little low strength Marcaine to anesthetize the area. The area was then exposed. I used a suture to attempt to try to
    tie the tag off, however, the material was exceedingly friable, however the tag was removed. I used both a disposable heat cautery as well as silver nitrate sticks to cauterize the area that was oozing. I then used Xeroform with a 4 x 4 to reduce the prolapsed rectum which reduced easily and packed with the Xeroform and 4 x 4s. The patient was then monitored. She remained stable for us. There was no more oozing from the rectum. I did send the specimen off for pathology. In addition, this was all done with the consent of the patient. She did receive a total of 100 mcg of fentanyl and 0.5 mg of Ativan during the procedure and tolerated this well.

    could I possibly use 45190? or would this have to be included in the E/M as no procedure code for this?
    thanks
    Basically destruction of a lesion so I would look at 46924.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. Default
    thank you for your response. I agree about the destruction but was wandering since the 46924 is for lesion of the anus and this was in the rectum. Would that still be ok?

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