Can you bill 46947 with 46945???
Digital rectal exam was dilatation of the anus confirmed findings of circumferential combined hemorrhoids and significant rectal prolapse of redundant mucosa. The PPH procedure was performed first-with insertion and anchoring of the plastic collar at the anus and then placement of a pursestring suture of 2-0 Prolene circumferentially well above the dentate line. Mucosa is markedly redundant and the open stapler is easily passed through the pursestring. The sutures then tied snugly against the shaft of the stapler, and the ends retrieved in the usual fashion. Stapler was then slowly closed and held in place for one minute to allow gentle pressure and aid with hemostasis. Stapler was then fired and again held in place for one minute before the stapler was opened and easily extracted from the anus. A ring of rectal mucosa is examined and although it is intact, and circumferential, it is probably not enough tissue volume to leave a significant amount of the rectal redundancy. Operating anoscope was inserted and the suture line was visualized. There is some brisk bleeding from the suture line a couple of places this was initially addressed with chromic sutures. It is also obvious that he still has significant external and combined hemorrhoidal tissue and a formal hemorrhoidectomy then proceeded as planned. Chromic sutures used to ligate proximal vessels at about the level of the staple line and then the redundant mucosa is resected in a radial fashion to include mucosa and submucosa in 3 separate quadrants. The resultant repair seems to fix the external prolapse, but digital rectal exam reveals that the staple line a somewhat small and because of the hemostatic chromic sutures that were placed, I felt this opening was inadequate. Therefore proctoscopy was performed and the scope passed through the staple line and retrieved.
Opinions???
Digital rectal exam was dilatation of the anus confirmed findings of circumferential combined hemorrhoids and significant rectal prolapse of redundant mucosa. The PPH procedure was performed first-with insertion and anchoring of the plastic collar at the anus and then placement of a pursestring suture of 2-0 Prolene circumferentially well above the dentate line. Mucosa is markedly redundant and the open stapler is easily passed through the pursestring. The sutures then tied snugly against the shaft of the stapler, and the ends retrieved in the usual fashion. Stapler was then slowly closed and held in place for one minute to allow gentle pressure and aid with hemostasis. Stapler was then fired and again held in place for one minute before the stapler was opened and easily extracted from the anus. A ring of rectal mucosa is examined and although it is intact, and circumferential, it is probably not enough tissue volume to leave a significant amount of the rectal redundancy. Operating anoscope was inserted and the suture line was visualized. There is some brisk bleeding from the suture line a couple of places this was initially addressed with chromic sutures. It is also obvious that he still has significant external and combined hemorrhoidal tissue and a formal hemorrhoidectomy then proceeded as planned. Chromic sutures used to ligate proximal vessels at about the level of the staple line and then the redundant mucosa is resected in a radial fashion to include mucosa and submucosa in 3 separate quadrants. The resultant repair seems to fix the external prolapse, but digital rectal exam reveals that the staple line a somewhat small and because of the hemostatic chromic sutures that were placed, I felt this opening was inadequate. Therefore proctoscopy was performed and the scope passed through the staple line and retrieved.
Opinions???