Jamie Dezenzo
True Blue
Hello all,
This one has me alittle confused....
Patient had a lateral internal sphincterotomy (46080) early in the day....
Then was sent back to the OR see op note:
PRE/POST DIAGNOSIS: Hemorrhoidal bleeding.
PROCEDURE PERFORMED: Examination under anesthesia and cauterization of bleeding.
ANESTHESIA: IV sedation.
INDICATIONS: This morning, had a lateral internal anal sphincterotomy. In the recovery room she did fine. In the Phase II she did very fine, and then as she began to stand up she noticed some bleeding from the site. Direct pressure was held but it still continued to bleed, so we brought her back to the operating room for coagulation.
FINDINGS: Operative findings include hemorrhoidal bleeding from the sphincterotomy site. This was controlled using direct pressure and electrocautery. Meticulous hemostasis was achieved as described above. We copiously irrigated the area, watched it for 10 minutes. There was absolutely no bleeding.
PROCEDURE: The patient was brought to the operating room and was placed in the left lateral decubitus position. IV sedation was induced by anesthesia. Next, we identified the old sphincterotomy site, and there was just some slow ooze of blood coming from that site; it seemed like hemorrhoidal-type venous blood. We held direct pressure for 10 minutes. There was still a little bit of bleeding. Next we cauterized this area using electrocautery. Then the bleeding completely stopped. It seemed like it was from the hemorrhoidal edge that was just underneath where we made the incision site. The bleeding completely stopped. We held this for another 10 minutes, and there was no bleeding. We copiously irrigated the wounds, trying to stir up the bleeding, and there was no bleeding that was able to be stirred up. Again we watched it for another 10 minutes; there was no bleeding, so we placed bacitracin ointment, Xylocaine jelly, Vaseline gauze and dry sterile dressings.
Would code 46930-79 998.11 from a ASC stand point....any thoughts?
This one has me alittle confused....
Patient had a lateral internal sphincterotomy (46080) early in the day....
Then was sent back to the OR see op note:
PRE/POST DIAGNOSIS: Hemorrhoidal bleeding.
PROCEDURE PERFORMED: Examination under anesthesia and cauterization of bleeding.
ANESTHESIA: IV sedation.
INDICATIONS: This morning, had a lateral internal anal sphincterotomy. In the recovery room she did fine. In the Phase II she did very fine, and then as she began to stand up she noticed some bleeding from the site. Direct pressure was held but it still continued to bleed, so we brought her back to the operating room for coagulation.
FINDINGS: Operative findings include hemorrhoidal bleeding from the sphincterotomy site. This was controlled using direct pressure and electrocautery. Meticulous hemostasis was achieved as described above. We copiously irrigated the area, watched it for 10 minutes. There was absolutely no bleeding.
PROCEDURE: The patient was brought to the operating room and was placed in the left lateral decubitus position. IV sedation was induced by anesthesia. Next, we identified the old sphincterotomy site, and there was just some slow ooze of blood coming from that site; it seemed like hemorrhoidal-type venous blood. We held direct pressure for 10 minutes. There was still a little bit of bleeding. Next we cauterized this area using electrocautery. Then the bleeding completely stopped. It seemed like it was from the hemorrhoidal edge that was just underneath where we made the incision site. The bleeding completely stopped. We held this for another 10 minutes, and there was no bleeding. We copiously irrigated the wounds, trying to stir up the bleeding, and there was no bleeding that was able to be stirred up. Again we watched it for another 10 minutes; there was no bleeding, so we placed bacitracin ointment, Xylocaine jelly, Vaseline gauze and dry sterile dressings.
Would code 46930-79 998.11 from a ASC stand point....any thoughts?