General Surgery Coding Alert

Question: I have a surgical note that states the surgeon did an “over-sewing” of a rectal ulcer. What would be the appropriate code for this?

Ohio Subscriber

Answer: You don’t mention endoscopy, so assuming that this is an open procedure, the best code choice is 45562 (Exploration, repair, and presacral drainage for rectal injury).  

You really can’t adequately assign a procedure code in this case without further documentation. If you ask your surgeon for documentation of the surgical approach and a more thorough description of the procedure, you might select a different code.