I am perplexed with how to code this. Provider states "skin tag was isolated with forceps and cut with scissors. No bleeding noted. Patient tolerated procedure well." This is not an excision, so I do not feel 46220 is appropriate. Also looked at the 46900 series, but do not feel any of those fit. Any idea’s?
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Tag Archives: perianal
Anal fistulotomy and excision of perianal mass
Any help on coding this would be great.
Wed Feb 08 10:41:24 2017 EST
Wed Feb 08 11:57:21 2017 EST
SURGEON: Dr A
PREOPERATIVE DIAGNOSIS: Anal fistula.
POSTOPERATIVE DIAGNOSIS: Anal fistula.
PROCEDURE: Anal fistulotomy and excision of perianal mass.
DESCRIPTION: With the patient supine with his legs up in
stirrups, under general anesthetic, the perianal area was
prepped with Betadine. After an appropriate time-out, the
anus was approached. A proctoscopy was done to 25 cm with
normal mucosa seen throughout. The proctoscope was then
withdrawn. Attention was then turned to the perianal exam.
There was a granulation tissue mass at the external opening
of the fistula at the 7 o’clock position with 6 o’clock being
the anterior midline. This was excised and sent for
pathologic evaluation. There was no obvious tract initially
at the skin of the incision, but at the depth it was obvious
that there was a tract that extended directly to the dentate
line in a radial fashion. This was opened. On examining the
perianal area, there was also a defect in the mucosa at the
anterior midline or 6 o’clock and this extended into a blind
sac which contained purulent material. This was laid open,
again using cautery. At the anterior incision, there was no
involvement of the sphincter complex. At the lateral
incision, the superficial sphincter was taken along with
opening the fistula tract. The hemostasis was assured with
cautery and then the wounds were packed with Cordran cream
and Gelfoam. Local anesthesia, 10 mL of Marcaine, was placed
prior to completion.
perianal lesion
Please help if you can. What codes would you use ?
DX- INTERNAL HEMORROHOID, external skin tag and perianal ulceration
Procedure :Hemmorrhoid ligation and excision of perianal lesions x3
Findings-One anterior midline anal skin tag, two right and left posterioe superficial ulcertations, and internal hemorrhoids ligated
A digital rectal exam was performed which demonstrated a right p0sterior anal papilla. A hill fergerson anal retractor was used to examine the distal rectal mucosa. The mucosa appeared redundant and showed some evidence of friability for mucosal prolapase. An anterior skin tag was excised with bovie electrocautery and the wound was left open. Two superficial ulcerations located on the perianal skin were excised .
Hemostasis was achieved with bovie electrocautery. A perianal block was created with exparel and thrombin gel foam inserted into the anal canal.
46922?46220? does any one see the ligation part ?
thanks for your time