tci General Surgery Coding Alert - 2013 Issue 6

Reader Question: Watch Setting For Terminated Procedure Modifiers

Question: Our surgeon identified an anal mass of approximately 3 cm upon digital rectal exam. The surgeon then attempted a transanal lesion excision under anesthesia, but did not complete the procedure. Following anal dilation with a retractor, the lesion was larger than expected (5 cm) and demonstrated centralized ulceration — two indicators that transanal excision is not appropriate. How should we code?Ohio Subscriber Answer: Because the attempted procedure was a simple surgical excision of an anal lesion, the most descriptive code is 46922 (Destruction of lesion[s], anus [e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle], simple; surgical excision)...

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