AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2023 Issue 2; Ask the Editor

V-Y Anoplasty and Excision of Mucosal Ectropion

A 50-year-old patient, status post intersphincteric proctectomy with colo-perineal anastomosis and pelvic radiation due to rectal cancer, is admitted for surgical treatment of an anal mucosal ectropion and fecal incontinence. During surgery, the mucosal ectropion was excised and V-Y anoplasty was done. An endorectal ultrasound revealed an absence of the internal sphincter. Examination revealed anal gaping and exposed rectal mucosa within the anal canal. The largest amount of exposed rectal mucosa was found on the patient's left side which was the site chosen for the anoplasty. A mucosectomy was performed with preservation of the muscularis propria. A skin advancement flap was performed using perianal skin, which was advanced into the anal canal. What is the appropriate root operation for the V-Y anoplasty procedure? When referencing "anoplasty" in the ICD-10-PCS index, root operations "Repair" and "Supplement" are listed as the root operation options. However, this procedure appears to meet the root operation definition for Transfer. Additionally, is it appropriate to separately report the excision of mucosal ectropion? What are the appropriate code assignments for this procedure? ...

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