Gastroenterology Coding Alert

Reader Questions: Rectal Exam With Anesthesia? Code 45990

- Published on Thu, Feb 10, 2011

Question: I can't seem to find a proper CPT code for this: The surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off but the large vessel underneath was continuing to bleed (all done under anesthesia). He then sutured the bleeding site. Any suggestions?

Answer: The procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). Do not report 45990 in conjunction with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma), according to CCI Edits.

Physician responsibility: Anorerctal exam is mainly done by placing the patient in left lateral decubitus position. This exam is mainly done to study Anal Fissures, Anal fistula, Anal mass [...]

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