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Mucosal rectal prolapse - 45130?

Tanesha Posted Thu 18th of October, 2018 10:16:08 AM
What CPT is suggested here? 45130 CDR doesn't quite match. EXCERPT: The perineum was prepped and draped in the usual fashion. He had a rectal prolapse of the mucosa on the right side greater than the left. I placed a Lone Star retractor to evert the anus. I then marched out with the Bovie about 1 cm distal to the dentate line. I then injected 0.25% Marcaine with epinephrine to create a submucosal plane with a lip of mucosal layer. I then used a needle tip cautery to dissect the rectal mucosa up to a level about 3-4 cm above the dentate line, which equaled about the amount of rectal prolapse he was having. I dissected more posteriorly on the right and the left side. Anteriorly he did not have much in the way of rectal prolapse, so I only got about 1-2 cm above the dentate line there. Next, I repaired the defect by repositioning the dentate line by suturing this with reefing the rectal wall circumferentially. The dentate line was repositioned in normal position
SuperCoder Answered Fri 19th of October, 2018 13:21:19 PM

Thanks for your question. You are correct CPT® 45130 is not the best choice for this procedure. Based on the information that you have provided, CPT® code 45541; Proctopexy (eg, for prolapse); perineal approach may be the most appropriate choice for what you have described. 

Tanesha Posted Sun 21st of October, 2018 21:41:14 PM
Ok, thank you for your response.
SuperCoder Answered Sun 21st of October, 2018 21:47:11 PM

You are welcome.

Tanesha Posted Mon 22nd of October, 2018 09:48:08 AM
According to the CDR, 45541 mentions levator muscle and the rectum being approximated to the sacrum. Is this code correct in relation to the op note? He did excise the rectal mucosa. CDR description - the physician approximates the rectum to the sacrum (proctopexy) for rectal prolapse. The physician makes a transverse incision between the anus and coccyx. Dissection is continued through the levator muscles to mobilize the rectum from the sacrum. The rectum is placed on upward tension to remove the redundancy and approximated to the sacrum with sutures or with a mesh wrapped around the rectum and secured to the sacrum. The incision is closed.
Tanesha Posted Mon 22nd of October, 2018 12:28:35 PM
Would 45505 work? (not sure) Flaps aren't mentioned in the op report like that of the CDR description.
SuperCoder Answered Mon 22nd of October, 2018 22:22:34 PM

Sorry for the confusion.  Your documentation fits well with a Delorme procedure which is for the shorter rectal prolapses.  According to the documentation, your provider excised the mucosa and then repaired the prolapse.  45505; Proctoplasty; for prolapse of mucous membrane is used for Delorme procedures.  Even though no flap was mentioned, the provider did mention that he excised the mucosa and sutured the rectal wall with reefing. This is typical with the Delorme procedure.

Tanesha Posted Tue 23rd of October, 2018 08:55:15 AM
45541 CPT code is for Delorme and it mentions the levator muscle and sacrum which isn't noted in my op report. 45505 CPT code sounds like the op note except for the flap part.
SuperCoder Answered Wed 24th of October, 2018 09:29:05 AM

Your operative note describes 45505.  The flaps wording is the only wording that is different from the general description of this procedure.  What your provider did in the documentation is what 45505 describes.  Even though your documentation did not mention flaps, the provider did mention that he sutured the rectal wall with reefing.  Another way this may be described in some medical encyclopedias is folds. 45505 best describes this procedure. 

Tanesha Posted Tue 18th of December, 2018 09:00:02 AM
Thank you!
SuperCoder Answered Tue 18th of December, 2018 23:47:24 PM

Happy to help!

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