"Incision and drainage (I and D), and excision of an anal rectal abscess cyst."
Can't locate CPT code for this procedure thinking unlisted 45999 - rectum and 45005 or 46045 for the I & D portion. I see related CPT
FINDINGS: Two separate, 1 completely closed and 1 with a small pinhole opening which was opened further, in the right anterior. Hydrogen peroxide was infused into the external opening to the fistulous tract. A clear internal opening was identified, but as we had discussed previously, he did not want any kind of a Seton drain or anything placed at this point. I did wide excisions of these 2 cystic abscess cavities and achieved hemostasis.
OPERATIVE PROCEDURE: While supine on a stretcher a general endotracheal anesthesia achieved. He was placed prone in jackknife position. The buttocks were taped apart using silk tape and Mastisol. _____ region was prepped and draped in standard surgical fashion. A timeout was performed and confirmed. I did a local block using Marcaine 0.5% infiltrated in 4 quadrants of the subcutaneous plane and 4 quadrants of the mucosal plane with a digit in the anal canal. Identified the abscess cavity in the right anterior. A small pinhole opening. I was able to place a fistula probe. I could not get it to go away through, and considering the fact also that we would not planning on putting a Seton drain at this point as per patient request, we just did not want to force the probe through. However, on infiltrating hydrogen peroxide half strength with saline, it easily went through and identified a radial internal opening to this fistula. I opened up both abscess cavities, debrided them out, achieved hemostasis. The one more posteriorly was pretty much completely closed, but I excised what I could, and there was no cystic wall, just opened the skin and debrided out some tissue. At this point there was good hemostasis. I packed both with quarter-inch packing, placed gauze, combine, and tape.
Can't locate CPT code for this procedure thinking unlisted 45999 - rectum and 45005 or 46045 for the I & D portion. I see related CPT
FINDINGS: Two separate, 1 completely closed and 1 with a small pinhole opening which was opened further, in the right anterior. Hydrogen peroxide was infused into the external opening to the fistulous tract. A clear internal opening was identified, but as we had discussed previously, he did not want any kind of a Seton drain or anything placed at this point. I did wide excisions of these 2 cystic abscess cavities and achieved hemostasis.
OPERATIVE PROCEDURE: While supine on a stretcher a general endotracheal anesthesia achieved. He was placed prone in jackknife position. The buttocks were taped apart using silk tape and Mastisol. _____ region was prepped and draped in standard surgical fashion. A timeout was performed and confirmed. I did a local block using Marcaine 0.5% infiltrated in 4 quadrants of the subcutaneous plane and 4 quadrants of the mucosal plane with a digit in the anal canal. Identified the abscess cavity in the right anterior. A small pinhole opening. I was able to place a fistula probe. I could not get it to go away through, and considering the fact also that we would not planning on putting a Seton drain at this point as per patient request, we just did not want to force the probe through. However, on infiltrating hydrogen peroxide half strength with saline, it easily went through and identified a radial internal opening to this fistula. I opened up both abscess cavities, debrided them out, achieved hemostasis. The one more posteriorly was pretty much completely closed, but I excised what I could, and there was no cystic wall, just opened the skin and debrided out some tissue. At this point there was good hemostasis. I packed both with quarter-inch packing, placed gauze, combine, and tape.