amanda19791
Networker
I need some advice to what code to use for the procedure below. I was thinking of 45990 but there is nothing stating diagnostic.
Findings:
Two separate superficial 1cm lacerations on either side of midline posterior to the anus and terminating just inside the anal mucosa. There was no internal injury.
Indication: Patient sustained an injury in the bathtub last night when apparently fell from standing onto buttock on a toy funnel. There was significant bleeding and the child was taken to the ED. Owing to inability to determine the extent of the injury, rectal exam under anesthesia is warranted. Patient is taken to the operating room on an urgent basis for exam under anesthesia following a discussion with the father regarding the procedure and its attendant risks including, but not limited to, bleeding and infection. He demonstrated good understanding and desired to proceed.
Procedure: The patient was placed in the supine position. Adequate anesthesia was initiated. The position was changed to frogleg. The buttocks were spread and examination was performed. A nasal speculum was used to assess the rectal mucosa. No injury required further treatment. Antibiotic ointment was applied. The procedure was well tolerated and there were no apparent complications.
Findings:
Two separate superficial 1cm lacerations on either side of midline posterior to the anus and terminating just inside the anal mucosa. There was no internal injury.
Description of Procedure: |
Indication: Patient sustained an injury in the bathtub last night when apparently fell from standing onto buttock on a toy funnel. There was significant bleeding and the child was taken to the ED. Owing to inability to determine the extent of the injury, rectal exam under anesthesia is warranted. Patient is taken to the operating room on an urgent basis for exam under anesthesia following a discussion with the father regarding the procedure and its attendant risks including, but not limited to, bleeding and infection. He demonstrated good understanding and desired to proceed.
Procedure: The patient was placed in the supine position. Adequate anesthesia was initiated. The position was changed to frogleg. The buttocks were spread and examination was performed. A nasal speculum was used to assess the rectal mucosa. No injury required further treatment. Antibiotic ointment was applied. The procedure was well tolerated and there were no apparent complications.