Pt had PPH (Stapled hemorrhoidectomy, 90 day post op) day 1.
Day 31: Pt complains of anorectal pain. Exam reveals protruding staple against lumen. MD states he can remove painful staple b/c PPH will be intact with the one remaining staple. He inserts anoscope and removes anterior staple. All of this took place in the office.
He wants to bill 46608-78 (anoscopy w/removal foreign body)with 937 (foreign body).
There is a V58.32 encounter for removal of staples but does this include internal staples? Also, would this not be considered post op care because he is dealing with post op pain from internal wound site and performs procedure in the office with no anesthesia.
I am going with post op care, unbillable, but would like feedback from other sources.
Anna Barnes, CPC, CEMC
Day 31: Pt complains of anorectal pain. Exam reveals protruding staple against lumen. MD states he can remove painful staple b/c PPH will be intact with the one remaining staple. He inserts anoscope and removes anterior staple. All of this took place in the office.
He wants to bill 46608-78 (anoscopy w/removal foreign body)with 937 (foreign body).
There is a V58.32 encounter for removal of staples but does this include internal staples? Also, would this not be considered post op care because he is dealing with post op pain from internal wound site and performs procedure in the office with no anesthesia.
I am going with post op care, unbillable, but would like feedback from other sources.
Anna Barnes, CPC, CEMC