Digestive ColonRectumAnus slide13 - AAPC

Documentation Dissection

SUBJECTIVE: Mr. X is here for follow up anal condylomata |1|. During his last visit two months ago I performed fulguration of several intra-anal and two perianal condylomata. He reports that he thinks they may have come back since he has been having itching. He denies any bright red blood per rectum.

PHYSICAL EXAMINATION: CONSTITUTIONAL: He is pleasant and appears well.

VITAL SIGNS: T 98.6, HR 56, BP 121/73, Weight 150 pounds.

RECTAL: Visual inspection of the anus in the prone jackknife position |2| reveals a 2 mm recurrent perianal condylomata |3| in the left lateral position with an addition 1 mm recurrent condylomata in the position midline. Digital rectal examination reveals good resting tone. No significant masses can be palpated. Anoscopy shows two small 1 mm intra-anal condylomata |4| in the posterior and anterior midline positions.

ASSESSMENT: Mr. X has developed several small perianal and intra-anal condylomata |5| since undergoing a fulguration two months ago. I did explain to him that they are most likely not the cause of his itching since all of them are fairly small. As far as itching is concerned I recommended the use of Calmoseptine cream which should help alleviate his symptoms. I also advised that he not excessively wash his perianal region which can wipe off the natural oils of the skin and contribute to itching. I did recommend that he undergo fulguration today.

PROCEDURE |6|: His perianal region was sterilely prepped in the usual fashion. A solution of 1% lidocaine with epinephrine buffered with sodium bicarbonate was instilled at the base of each condylomata in the left lateral and posterior midline positions on the perianal skin. The condylomata were fulgurated with Bovie electrocautery and the base wiped clean with suction followed by repeat fulguration. A large anoscope was inserted into the anal canal revealing intra-anal condylomata in the posterior midline and anterior midline positions as above |7|. A solution of 1% lidocaine with epinephrine buffered with sodium bicarbonate was instilled at the base of each of the intra-anal condylomata using a 25 gauge spinal needle through the anoscope. The condylomata were fulgurated with Bovie electrocautery and the base wiped clean with suction followed by repeat fulguration |8|. A smoke evacuator and TB masks were used.

PLAN: I performed fulguration of several perianal and intra-anal condylomata on Mr. X today. He has Lortab left over from his last fulguration from two months ago. I will see him back for follow-up in three months for continued surveillance.

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|1| Condylomata is plural for condyloma.

|2| Patient is face down, legs bent--patient is rolled forward for access to rectal area.

|3| Perianal condylomata identified.

|4| Condyloma are located in the anus.

|5| Indication for procedure and final diagnosis.

|6| The operative note is included in the office note documentation. This is acceptable documentation.

|7| Anoscopy used to identify intra-anal condylomata. This has separate procedure designation.

|8| Identifies fulguration of intra-anal conylomata using electrocautery.

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What CPT? and ICD-10-CM codes are reported? CPT? Code: 46910 ICD-10-CM Code: A63.0 Rationales: CPT?: Fulguration is destruction and removal of tissue using high-frequency electric current applied with a needlelike electrode. In the CPT? Index locate Destruction/Lesion/Anal with code range 46900?46917, 46924. This code range identifies the destruction of lesions of the anus by various methods. A review of the codes identifies 46910 as the electrodessication of lesions of the anus (eg, condyloma) and is the correct code. ICD-10-CM: The medical term for anal warts in adults is condyloma acuminatum. This is the human papillomavirus (HPV) that affects the mucosa and skin of the anorectum and genitalia. In the ICD-10-CM Alphabetic Index locate Condyloma/acuminatum leading to A63.0. The Tabular Lists confirms A63.0 Anogenital (venereal) warts is correct.

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