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Posted By Danielle Levy on 01-17-2019, 14:24:54 in Ob-Gyn
I am new to URO/GYN and am stumped with this procedure .

A 3CM mass was palpable on vaginal exam, rectal exam and also through the skin in the right buttock. A 3CM incision was made and the mass was isolated. It was removed and appeared not to have any obvious infectious or hematologic etiology associated . The base was sutured and then rectal and vaginal exam showed no communication with rectum or vagina . Cystoscopy also was benign with no communication with the mass . The dead space was then closed using 00-vicryl and skin was closed over it using interrupted sutures .

Path came back with fragments of adipose tissue with fat necrosis
Our physician suggested codes 45160 vs 45171 VS 45172 I dont feel these are correct , I leaned more towards 11424 but still have uncertanity . Please advise
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Posted By Melanie Witt on 01-18-2019, 13:33:55
It is not clear from this description exactly how the mass was excised - that is the approach. If it was through the skin of the buttocks they you report an integumentary code by location and size and in this case it appears to be an intermediate closure. I see no evidence in this report that 45160 would be correct. This procedure involves making an incision at the junction of the sacrum and coccyx. The coccyx is then excised and dissection is continued posteriorly to mobilize the rectum. The tumor is identified, an incision is made in the rectum (proctotomy), and the tumor is excised. The rectum is closed with sutures or staples. The initial incision is closed. Likewise, 45171 and 45172 would instead require that the tumor was excised from inside the anal canal - also not described here. I would go back and discuss this with the provider and if necessary an addendum to the op report would be needed to bill any of the suggested codes.
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