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Postoperative rectal bleeding

Lee Posted Wed 06th of August, 2014 13:43:03 PM

An EUA was performed along with the Litigation of two Bleeding vessels after a transanal excision of a rectal lesion was performed the day before. what CPT code to use?

SuperCoder Answered Wed 06th of August, 2014 21:53:24 PM

Thanks for your question. 45990; Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic. Anorerctal exam is mainly done by placing the patient in left lateral decubitus position. This exam is mainly done to study Anal Fissures, Anal fistula, Anal mass and Hemorrhoids. The patient is given general, spinal or epidural anesthesia and the physician performs a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter mainly to examine the perineal area. An ansoscope is inserted into the rectum to visualize the anal canal and distal rectum. After removing the anoscope a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.

You would need to select the appropriate code based on the method of ligation.
46221, Hemorrhoidectomy, internal, by rubber band ligation(s)

46945; Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group

46946; Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups

You may need to apply modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) if a subsequent procedure by the same surgeon falls within the global period of an earlier surgery. Hope this helps.

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