1. maarit v
   Posted 3 months ago #
   

   The PT had hemorrhoidectomy 3 days ago and was now taken to OR due to continued post-op bleeding. The surgeon cauterized some raw bleeding wound edges inside the rectum and also stiched some. Do I need to use 45999 (unlisted) for this and what would be a good reference code on line 19?
   thanks

2. SuperCoder
   Posted 3 months ago #
   

   If the procedure performed justifies, then you can use cpt 45317 Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
   with modifier -78 (return to the operating room for a related procedure during the postoperative period) attached. This modifier needs to be used, then it has to be used in the global period of hemorrhoidectomy.

   Note: If the above CPT doesn't fit into it, you can use an Unlisted code in stead.

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