# transanal excision/rigid sigmoidscopy



## BABS37 (Mar 14, 2012)

I have a question on if these are the right codes or if I'm in the wrong spot. Can someone please help? She came in for two surgeries due to bleeding.

day one note: transanal excision of full thickness rectal mass (thinking 45172)

She was positioned in the prone jack knife position. The rectum, anus, and perineum were prepped and draped. Anus was digitally dilated and Hill-Ferguson retractor was inserted. The lesion was identified as was found previously on colonoscopy and was in the expected position with the lower most extent of the mass not more than 2cm from the anal verge just at the upper limits of the sphincter and extending about 5cm up from there. The width of the mass extended from the 7oclock position anteriorly on the left around to the 2 oclock position posteriorly on the right. The anal margin was grasped with an Allis and retracted inferiorly. The lower most tip of teh mass was greasped and elevated, the mucosa was incised with a couple mm's of grossly clear margin. The full thickness of rectal wall was taken as the lesion was completely excised. Minor arterial which was bleeding was ligated with 3-0 vicryl. 

day four note: exam under anesthesia and ligation of small arterial bleeder in wound bed of previous excision and a rigid sigmoidoscopy ( 45334 vs 45300- 78 unplanned? so not sure which code) it sounds like he just sewed it up... 

Lubricated Hill-Ferguson retractor was placed and a large amount of clotted blood and bright red blood was evacuated from the rectal vault. The area was irrigated and the wound bed from the previous transanl excision was examined. Mucosal stitched had dehisced over the majority of the suture line and the mucosa was gaping open where the stitches had pulled through. At the superior end of the wound bed to the left side of teh midline anteriorly was a small arterial bleeder. The was ligated with 3-0 chromic figure of eight suture. The edges were a bit ragged. The depth showed of the wound showed no evidence of tracking out into the perirectal fat. Rigid sigmoidoscopy was then completed well past the area of excision. Clotted blood was evacuated from the sigmoid colon, which had pooled there and no additional bleeding was noted. The scope was withdrawn.


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## acbarnes (Mar 15, 2012)

Procedure Day 1: 45172 (MD states full thickness of rectal taken with lesion)

Procedure Day Four: Bleeding oversew of wound in rectum, use 45999-78 unlisted rectum. He did not state he used a flex sig to oversew so you cannot use 45334 and rigid was done to check site to confirm no further bleeding wihich is inclusive (see CMS guidelines for global package referencing interoperative scopes). I would use RVU similar to 46945 for the unlisted code.

Anna Barnes, CPC, CEMC


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