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CPT 46040 documentation

Kelly Posted Mon 26th of November, 2012 17:24:43 PM

Does this op note support billing cpt 46040, and what diagnosis
code(s) would you use?

Patient is currently being treated for a perirectal abscess. Upon inspection of the gluteal area, there is an area of induration and swelling directly adjacent to the previous open abscess area.

PROCEDURE: The gluteal area was cleansed with some Betadine, anesthetized with 2 percent Xylocaine approximately 4 mL and good anesthesia was obtained. A cruciate incision was made directly over the area of swelling and induration. About a 2 x 2 centimeter incision was made. It was then probed fairly deeply with a mosquito and I could not really identify any pockets of pus. It seemed to be I think fairly normal but slightly inflamed looking tissue only.

ASSESSMENT: Perirectal swelling and irritation. No evidence of an abscess on I and D today.

SuperCoder Answered Mon 26th of November, 2012 22:25:13 PM

"I could not really identify any pockets of pus", this lead me to code for 46040-52 with 569.49.

The procedure is identical to 46040 but in a reduced manner.

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