Forum - Questions & Answers

Jun 21st, 2012 - rhorton4 22 

Rectal mass

Can anyone help me? I need CPT® code for op note below.

The patient was known to have a rectal mass for greater than a year. We performed a sigmoidoscopy to make sure that there were no other lesions in the rectum. Retroflexion revealed the single mass with what appeared to be 2 small verrucous lesions at the anal verge. The mass measured approximately 1.5 cm x 0.5 cm. We took out the scope, placed an anal retractor in place, and used the Bovie to cauterize the mass, including small amount of mucosa. Two small verrucous lesions were fulgurated, and the lesion was sewn up using a running 3-0 chromic suture.

Doc coded 45331 & 45171. Not sure if this is right. any help would be appreciated.



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