General Surgery Coding Alert

Question: Our surgeon identified an anal mass of approximately 3 cm upon digital rectal exam. The surgeon then attempted a transanal lesion excision under anesthesia, but did not complete the procedure. Following anal dilation with a retractor, the lesion was larger than expected (5 cm) and demonstrated centralized ulceration — two indicators that transanal excision is not appropriate. How should we code?

Ohio Subscriber

Answer: Because the attempted procedure was a simple surgical excision of an anal lesion, the most descriptive code is 46922 (Destruction of lesion[s], anus [e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle], simple; surgical excision).

However, because the surgeon aborts the procedure without completing the excision, you’ll need to append modifier 53 (Discontinued procedure). This is the appropriate modifier when the surgeon terminates the procedure post-anesthesia due to “extenuating circumstances or those that threaten the well-being of the patient,” according to the CPT^® modifier explanation.

ASC is different: If the surgeon performs the procedure in an outpatient hospital/ambulatory surgery center (ASC) setting, you’ll need to use a different modifier, because 53 is not approved for those sites. Instead, turn to modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration), both of which are approved for ASC/hospital outpatient use.