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 and Hemorrhoids. The patient is [...]

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