Sara Posted Thu 25th of June, 2020 15:29:53 PM
Can you please advise how to code the following procedure. I chose 45150, 1404X. I queried the provider for the size of the flap, and the provider stated that was not necessary. I then asked an outside source and was told this was incorrect coding for the flap. I need to know how the flap would be coded, if at all,, and if 1404X is correct, can it be coded without the size being documented?
POST OPERATIVE DIAGNOSIS: Rectal stricture.
1. Division of rectal stricture.
2. Endorectal advancement flap for repair of stricture.
DESCRIPTION OF PROCEDURE:
After informed consent, the patient was brought to the operating room, underwent
general endotracheal anesthesia, placed in a prone jack-knife, prepped and draped
in standard fashion. Lone Star applied. Marcaine and Exparel injected. I then
did a digital rectal exam, could not pass the finger. I was able to pass the
smallest Sawyer retractor with some pressure and was able to barely cross the
stricture. I then divided the stricture with cautery and allowed opening of the
rectum more. It was not on the anal canal. It is higher in the distal rectum. It
was on the mucosa itself, which was certainly an uncommon place for stricture here
after hemorrhoidectomy. After dividing the stricture, I then placed a medium
Sawyer and then basically elevated a flap of endorectal mucosa up incorporating all
the stricture and removing the stricture and then mobilized wide endorectal
advancement flap with good perfusion and then advanced it across the area of
stricture and closed. I made a transverse shaped closure with interrupted
3-0 Vicryl pops. I then used Vistaseal to seal in the anal canal and to help heal
the wound line. Bulky dressing was applied. The patient taken to recovery room in
SuperCoder Answered Fri 26th of June, 2020 10:23:45 AM
Sara Posted Mon 29th of June, 2020 09:08:57 AM
I needed to know how to code the endorectal advancement flap. I included the op note for context. Is this something I can get answered?
SuperCoder Answered Tue 30th of June, 2020 12:49:54 PM
Thanks for the query.
As per the provided documentation, CPT 1404X is incorrect code for endorectal advancement flap. CPT 1404X is used for integumentary structures, but the procedure has been performed on rectum for which there is specific code range.
There is no specific code for endorectal advancement flap. So, the appropriate code for endorectal advancement flap will 45999 (Unlisted procedure, rectum).
Reporting an unlisted-procedure code will require a special letter of explanation to describe the service, so attach the copy of operative report to justify the claim and to avoid payment deduction.
Hope this helps!
Sara Posted Tue 30th of June, 2020 13:32:02 PM
Thank you for your response.
SuperCoder Answered Wed 01st of July, 2020 00:36:11 AM
Thank you, happy to help.