[Answered]: Using the current year CPT manual, provide the…

Using the current year CPT manual, provide the procedure code the patient case. PREOPERATIVE DIAGNOSIS: Anal fissure. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: 1. Sphincterotomy. 2. One quadrant hemorrhoidectomy. SURGEON: Meridian Casha, MD ANESTHESIA: Spinal. INDICATION: The patient is a pleasant 46-year-old female who is 120 days post three quadrant hemorrhoidectomy for severe external hemorrhoids. She has an anal fissure as well as the external hemorrhoid and that is quite tender. She presents today for elective sphincterotomy, excision of the external hemorrhoid, understands surgery and the risks of bleeding, infection, and possible damage to the sphincter muscles and wishes to proceed. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, given spinal anesthesia, and placed in a jackknife position. We could see the enlarged hemorrhoid/sentinel tag at the 10 oclock position and the fissure right at the base of this. Anoscope was placed and we placed a Kelly clamp behind the hypertrophied scarred band of muscle and divided the muscle. We then excised the external hemorrhoid and then closed the defect with interrupted 3-0 chromic sutures and running locked 3-0 chromic. There were no other hemorrhoids and there were no other fissures. We infiltrated the area with a total of 30 cc of 0.5% Sensorcaine with epinephrine solution, placed four gauze dressings in the area that we will remove in 30 minutes, and she was taken to recovery in stable condition.