Operative Report
Preoperative diagnosis: Internal hemorrhoids
Postoperative diagnosis: Internal hemorrhoids, anal fistula
Procedure performed: Hemorroidectomy and repair of anal fistula
Operative note: The patient presented today for an inpatient procedure to repair an anal fistula and remove internal hemorrhoids. The patient was put under general anesthesia, prepped, and draped. The physician entered the anus using an endoscope to determine placement of internal hemorrhoids and, upon entering, identified an intersphincteric anal fistula that had occurred since the last visit by the patient. The procedure was initiated, and removal of two columns of internal hemorrhoids was performed using rubber band ligation. Once that procedure was performed, an endoscopic repair of the anal fistula took place, using fibrin glue to seal the fistula. With this accomplished, the patient was awakened from anesthesia and taken to an inpatient room for an overnight stay.
Select the appropriate CPT and ICD-10-CM codes:

Question

Quizplus · Accepted Answer

The correct CPT codes for the procedures described are 46221 for the hemorrhoidectomy using rubber band ligation and 46706 for the repair of the anal fistula with fibrin glue, with modifier -59 to indicate that it is a distinct procedural service. The correct ICD-10-CM codes are K64.8 for internal hemorrhoids and K60.3 for an intersphincteric anal fistula, matching the postoperative diagnoses.

Operative Report Preoperative Diagnosis: Internal Hemorrhoids