# perianal mass excision??? CPT code? TIA



## MELJNBBRB (Apr 23, 2014)

Any guidance is greatly appreciated!
Melissa Bedford,CCS,CPC


PREOPERATIVE DIAGNOSIS(ES):
Perianal mass.

POSTOPERATIVE DIAGNOSIS(ES):
Perianal mass.

PROCEDURE(S)/OPERATION(S) PERFORMED:
Excision of perianal mass.

FIRST ASSISTANT:

ANESTHESIA:
GETA.

ESTIMATED BLOOD LOSS:
Minimal.

IV FLUIDS:
400.

SPECIMENS:
Specimens to lab include perianal mass 2 cm x 1 cm.

INDICATIONS FOR OPERATION:
The patient is a 58-year-old male, who has had a perianal
swelling for some time.  He was diagnosed with either a
hemorrhoid or versus mass at an outside facility.  He is placed
on antibiotics and the mass shrunk; however, it continued to
cause him problems.  He is a patient of mine from a prior
surgical intervention, and after discussion of the risks and
benefits of the surgery, he agreed to proceed with my recommended
course of excision of this mass.

PROCEDURE IN DETAIL:
The patient was taken to the operating room, placed supine on the
operating table.  After adequate general endotracheal anesthesia
was given, he was prepped and draped in the usual fashion.  This
is that he was placed in the candy-cane position.  With the
patient prepped, a 2.5-cm incision was made over the mass itself
and this was grasped and taken down to the external anal
sphincter muscles and surrounding soft tissues.  This mass was
just off the midline in the perineal area.  It did not involve
the rectum itself or the perianal skin that was outside of this
area.  With the mass excised and the bleeding controlled with
electrocautery, it was irrigated and closed with a simple suture
and then packed.  The patient tolerated the procedure well.  He
was extubated at the end of the case and taken to PACU.


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