EbonyS123
Networker
Have anyone ever seen this type of procedure? If so, what code are you all using ???
I am leaning towards 46930 but the word destruction makes me second guess.
Thanks
POSTOPERATIVE DIAGNOSIS: Hemorrhoids.
OPERATION/PROCEDURE PERFORMED: Examination under anesthesia and
hemorrhoidectomy.
ANESTHESIA: General endotracheal anesthesia.
DRAINS AND TUBES: None.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMENS: Included a right anterior hemorrhoid and a right posterior
hemorrhoid.
INDICATIONS FOR PROCEDURE: The patient is a 65-year-old male with
symptomatic hemorrhoids. He now desires repair. He has acknowledged the
risks and benefits, including the specific risks of anal pain and fecal
incontinence, bleeding, infection, and recurrent hemorrhoids. He
understands these risks and is willing to proceed.
OPERATIVE FINDINGS: Two right-sided hemorrhoids that were internal.
DESCRIPTION OF PROCEDURE: After informed consent was signed, the patient
was brought to the operating room and placed in the supine position.
Sequential compression devices were placed on his lower extremities
bilaterally. Antibiotics were not indicated for this procedure. After
general endotracheal anesthesia was induced without difficulty, and he was
then flipped supine. A brief pause was then made to note the patient's
name, site of surgery, and any patient allergies.
After the pause, we did an examination under anesthesia where we noted 2
internal hemorrhoids on the right. There were no other findings in the
anal canal that were suspicious.
We then directed our attention to the right posterior hemorrhoid. We
injected lidocaine at the base of this and made an incision using
electrocautery below this. We took care to avoid injury to the anal
sphincter during this process. We then took the incision down in wedge
fashion using a Ligasure down to the base of the hemorrhoid. We then
sewed this up at the mucosal level using 2-0 chromic, leaving the most
distal aspect of the incision or that area just outside the anal canal
open for adequate drainage. We then proceeded to do the exact same
procedure to the right anterior bundle using a ligasure until close. Once
this was all completed, we inserted dibucaine ointment and a Gelfoam into
the anus, and the patient was awakened from anesthesia. The specimens
were sent off for pathologic review. Hemostasis was achieved throughout.
I am leaning towards 46930 but the word destruction makes me second guess.
Thanks
POSTOPERATIVE DIAGNOSIS: Hemorrhoids.
OPERATION/PROCEDURE PERFORMED: Examination under anesthesia and
hemorrhoidectomy.
ANESTHESIA: General endotracheal anesthesia.
DRAINS AND TUBES: None.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMENS: Included a right anterior hemorrhoid and a right posterior
hemorrhoid.
INDICATIONS FOR PROCEDURE: The patient is a 65-year-old male with
symptomatic hemorrhoids. He now desires repair. He has acknowledged the
risks and benefits, including the specific risks of anal pain and fecal
incontinence, bleeding, infection, and recurrent hemorrhoids. He
understands these risks and is willing to proceed.
OPERATIVE FINDINGS: Two right-sided hemorrhoids that were internal.
DESCRIPTION OF PROCEDURE: After informed consent was signed, the patient
was brought to the operating room and placed in the supine position.
Sequential compression devices were placed on his lower extremities
bilaterally. Antibiotics were not indicated for this procedure. After
general endotracheal anesthesia was induced without difficulty, and he was
then flipped supine. A brief pause was then made to note the patient's
name, site of surgery, and any patient allergies.
After the pause, we did an examination under anesthesia where we noted 2
internal hemorrhoids on the right. There were no other findings in the
anal canal that were suspicious.
We then directed our attention to the right posterior hemorrhoid. We
injected lidocaine at the base of this and made an incision using
electrocautery below this. We took care to avoid injury to the anal
sphincter during this process. We then took the incision down in wedge
fashion using a Ligasure down to the base of the hemorrhoid. We then
sewed this up at the mucosal level using 2-0 chromic, leaving the most
distal aspect of the incision or that area just outside the anal canal
open for adequate drainage. We then proceeded to do the exact same
procedure to the right anterior bundle using a ligasure until close. Once
this was all completed, we inserted dibucaine ointment and a Gelfoam into
the anus, and the patient was awakened from anesthesia. The specimens
were sent off for pathologic review. Hemostasis was achieved throughout.
