tci General Surgery Coding Alert - 2011 Issue 7

Reader Question: Beware Upcoding to Anal Excision

Question: Patient presented with anal bleeding from a large vessel underneath a site where a hemorrhoid had necrosed and fallen off. Under anesthesia, the surgeon used a bivalve to suction old blood and suture the bleeding site. How should we code this? Missouri Subscriber Answer: The procedure you describe is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). Watch for edits: Do not report 45990 with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital...

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