Any help on coding this would be great.
Wed Feb 08 10:41:24 2017 EST
Wed Feb 08 11:57:21 2017 EST
SURGEON: Dr A
PREOPERATIVE DIAGNOSIS: Anal fistula.
POSTOPERATIVE DIAGNOSIS: Anal fistula.
PROCEDURE: Anal fistulotomy and excision of perianal mass.
DESCRIPTION: With the patient supine with his legs up in
stirrups, under general anesthetic, the perianal area was
prepped with Betadine. After an appropriate time-out, the
anus was approached. A proctoscopy was done to 25 cm with
normal mucosa seen throughout. The proctoscope was then
withdrawn. Attention was then turned to the perianal exam.
There was a granulation tissue mass at the external opening
of the fistula at the 7 o'clock position with 6 o'clock being
the anterior midline. This was excised and sent for
pathologic evaluation. There was no obvious tract initially
at the skin of the incision, but at the depth it was obvious
that there was a tract that extended directly to the dentate
line in a radial fashion. This was opened. On examining the
perianal area, there was also a defect in the mucosa at the
anterior midline or 6 o'clock and this extended into a blind
sac which contained purulent material. This was laid open,
again using cautery. At the anterior incision, there was no
involvement of the sphincter complex. At the lateral
incision, the superficial sphincter was taken along with
opening the fistula tract. The hemostasis was assured with
cautery and then the wounds were packed with Cordran cream
and Gelfoam. Local anesthesia, 10 mL of Marcaine, was placed
prior to completion.
Wed Feb 08 10:41:24 2017 EST
Wed Feb 08 11:57:21 2017 EST
SURGEON: Dr A
PREOPERATIVE DIAGNOSIS: Anal fistula.
POSTOPERATIVE DIAGNOSIS: Anal fistula.
PROCEDURE: Anal fistulotomy and excision of perianal mass.
DESCRIPTION: With the patient supine with his legs up in
stirrups, under general anesthetic, the perianal area was
prepped with Betadine. After an appropriate time-out, the
anus was approached. A proctoscopy was done to 25 cm with
normal mucosa seen throughout. The proctoscope was then
withdrawn. Attention was then turned to the perianal exam.
There was a granulation tissue mass at the external opening
of the fistula at the 7 o'clock position with 6 o'clock being
the anterior midline. This was excised and sent for
pathologic evaluation. There was no obvious tract initially
at the skin of the incision, but at the depth it was obvious
that there was a tract that extended directly to the dentate
line in a radial fashion. This was opened. On examining the
perianal area, there was also a defect in the mucosa at the
anterior midline or 6 o'clock and this extended into a blind
sac which contained purulent material. This was laid open,
again using cautery. At the anterior incision, there was no
involvement of the sphincter complex. At the lateral
incision, the superficial sphincter was taken along with
opening the fistula tract. The hemostasis was assured with
cautery and then the wounds were packed with Cordran cream
and Gelfoam. Local anesthesia, 10 mL of Marcaine, was placed
prior to completion.