tci General Surgery Coding Alert - 2013 Issue 5

Reader Question: Zero In on Rectal Lesion Excision Code

Question: The surgeon documents “external excision of rectal lesion with primary closure.” What is the correct CPT code for this procedure — 46220? Tennessee Subscriber Answer: No, 46220 (Excision of single external papilla or tag, anus) is not the best code choice, because the surgeon’s note involves the rectum, not anus, and a lesion, not a papilla or tag. A better choice would be 45171 (Excision of rectal tumor, transanal approach; not including muscularis propria [i.e., partial thickness]). Documentation support: The surgical note implies a transanal approach based on the fact that the surgeon specifies...

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