Question

Find CPT and ICD-10-CM Code

LOCATION: Inpatient, Hospital

PATIENT: Russell Cornwall

SURGEON: Larry P. Friendly, MD

PREOPERATIVE DIAGNOSIS: Anal fistula

POSTOPERATIVE DIAGNOSIS: Anal fistula

TITLE OF PROCEDURE: 1. Fistulotomy. 2. Anoscopy.

ANESTHESIA: General

INDICATIONS: The patient is a 46-year-old male with fever of unknown origin whom I had seen several months ago with perianal fistula. Since that time, he has had decreased drainage but still has pain and fevers. He presents today for elective fistulotomy, and he understands the risk of bleeding and infection and the possible risk of damage to the sphincter muscle, and he wishes to proceed with procedure. The patient was brought to the operating room, placed under spinal anesthesia, placed in the jackknife position, and prepped and draped sterilely. Digital rectal examination was first performed, and there were no masses. Anoscopy was then performed, and there was no internal anal fistulous opening. At the 4 o’clock position, we could feel this hard, indurated mass that drained purulent material. We then opened this with a no. 15 blade and debrided a necrotic capsule from this area. We then cauterized the base, injected it with 30 cc of 0.5% Sensorcaine with epinephrine solution, and packed it with 4 3 4 gauze. The patient tolerated this well and was taken to the postanesthesia recovery room in stable condition.

Answer 1

ANSWERS

ICD-10-CM code

            * K60.3 - Anal fistula.

CPT Codes

            * 46270 - Surgical treatment of anal fistula (fistulotomy/fistulectomy); subcutaneous.

                          ( Anoscopy is a part of fistolotomy procedure so no seperate code needed for it.)

            * 00902 - Anesthesia for anorectal procedure.