Nicole Posted Thu 19th of January, 2017 19:37:36 PM
Patient had a previous fistulectomy done and had some inflammation.
The doctor did the following: An attempt was made to find the tract but this was not possible. The external portion was then opened and excised. Hydrogen peroxide was inserted into the supposed tract but no tract could be palpated.
The doctor possibly thinks the MRI showed this to be scar tissue rather than a fistula tract.
The external part of the supposed tract was then excised.
Would this just be a complex repair code 1313_(depending on length) since this looks to be more of a scar.
SuperCoder Answered Fri 20th of January, 2017 01:37:34 AM
Could you please provide some more details regarding the same?
Above details will help us determining an appropriate code.
Nicole Posted Fri 20th of January, 2017 09:33:09 AM
The only information I have states this:
The perianal region was prepped.
Basically the external part of the supposed tract (possibly scar tissue) was then excised.
Does this information help any? Otherwise I will have to speak with the doctor about this more.
SuperCoder Answered Mon 23rd of January, 2017 08:19:03 AM
As per the MRI report, scar tissue was identified rather than a fistula tract. Hence, it indicates that scar tissue was excised, not the Fistula Tract.
Since, the external part of scar tissue was excised, so the appropriate code would be as per the following code range (11420-11426). To determine the code, check for the size of the scar tissue.