Cheryl Posted Tue 20th of August, 2019 16:00:14 PM
A patient had a sphincterotomy done and due to severe pain during the post op period the physician took him back to the OR and during the exam noticed the patient had superficial tunneling from the distant end of the lateral internal sphincterotomy site to the skin. With a 15 blade he open the area and unroofed it showing chronically poor healing tissue underneath. The was all superficial to the sphincter muscles. What CPT code would be best used.
SuperCoder Answered Wed 21st of August, 2019 10:15:19 AM
Thank you for your question. Since the above procedure performed is a complication of previous procedure and patient is retured to OR during post op period, so the appropriate code to bill will be cpt 46200 with modifier 78. Feel free to ask for any further query.