# Excision of rectal lesion



## NESmith (Sep 12, 2012)

Preoperative Details:
This 50-year old man was seen in my office a few weeks ago sent by his GI provider who performed a colonoscopy and found several polyps as well as rectal lesion sitting on top of a hemorrhoid. He was sent to me for removal and excision of the lesion. 
Operative Details: 
patient was taken to OR room and given MAC. As soon as patient was suffucuently sedated, he was placed in the dorsal lithotomy position into the Allen stirrups. Usual Betadine prep and sterile dressings were applied to the patient. At this time, anoscope was placed into the anal canal and the lesion was identified in the left lateral postion. It was sitting on top of some mild amount of hemorrhoid tissue. Approximately 1cc of 0.25% Marcaine with epinephrine was injected into the base of the lesion. An Allis clamp was used to grasp the lesion and traction was applied. A small hemostat was used to clamp the lesion. Curved tenotomy scissors were used to excise the tissue. the edges and base were cauterized and good hemostasis was noted. A 0-chromic suture was used to sew a figure-eight into the small wound. A #100 gel foam soaked in topaical thrombin was placed upon the wounds. A pressure dressing consisting of folded 4x4s and ABD pad were affixed into place using Microfoam tape.
Patient was sent to recovery room in stable condition.

Would you code this procedure 45171? Lot of different opinions. Thank You for your help in this matter.


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## Robin R (Sep 14, 2012)

The report says an anoscope was used, what about 46615?  Just a thought.


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