Resolved Anal fistula and I&D of anal abscess

[LoganR_46098]

Hello all,

A member of my team has been dinged by our internal auditors for coding 46270 and 46050 on the same claim, stating they are not separately reportable. Here is a description of the surgery:

"A hill ferguson retractor was placed to visualize the rectum and anal canal. No internal opening was initially seen. A small incision was made over the area of greatest fluctuance 1 cm from the anal verge and 5ml of pus drained. A lacrimal probe was used to identity the fistula tract. A primary fistulotomy was performed with electrocautery and the base of the tract debrided."

We believe that submitting 46270 and 46050 is appropriate because there are no NCCI edits pulling up on our coding assisting software when we enter these two codes. Are we in the right on this one?

 

[Darcy]

Hello all,

A member of my team has been dinged by our internal auditors for coding 46270 and 46050 on the same claim, stating they are not separately reportable. Here is a description of the surgery:

"A hill ferguson retractor was placed to visualize the rectum and anal canal. No internal opening was initially seen. A small incision was made over the area of greatest fluctuance 1 cm from the anal verge and 5ml of pus drained. A lacrimal probe was used to identity the fistula tract. A primary fistulotomy was performed with electrocautery and the base of the tract debrided."

We believe that submitting 46270 and 46050 is appropriate because there are no NCCI edits pulling up on our coding assisting software when we enter these two codes. Are we in the right on this one?

Based on the description provided, I do not believe it would be appropriate to report both 46270 and 46050 on the same claim for this procedure.

The National Correct Coding Initiative (NCCI) includes Column 1/Column 2 edits that prevent coding certain pairs of codes together if they are considered bundled or mutually exclusive. While there is no specific NCCI edit between 46270 and 46050, the coding guidelines indicate these codes should not be reported together for the same procedure.

Here's a breakdown of the codes:

46270 - Fistulotomy; anorectal, subcutaneous

This code describes the primary fistulotomy procedure performed to treat the anal fistula. Based on the op note, this involved using electrocautery to open up the fistula tract.

46050 - Incision and drainage of ischiorectal and/or perirectal abscess

While an incision and drainage was performed to release purulent material, this was done in order to identify and access the fistula tract, not as a separately identifiable procedure. Per CPT guidelines, incision and drainage integral to performance of other procedures is not reported separately.

Since the incision and drainage was performed as part of the exposure for the fistulotomy, and not treated as a separate abscess procedure, it would be considered bundled into 46270 and not separately billable.

The auditors are correct that 46270 and 46050 should not be reported together in this instance. I would recommend appealing the audit citing the CPT coding guidelines to support billing only 46270. Let me know if you need any additional clarification or have other questions!