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Posterior levatorplasty and Perineal proctoplasty for rectal prolapse

Tanesha Posted Tue 16th of October, 2018 10:51:34 AM
What code would you use for the Levatorplasty and Proctoplasty? 45505? I only came up with an unlisted code for the Levatorplasty. EXCERPT: I then opened up the pouch of Douglas and made sure that there was no redundant sigmoid in the pelvis. There was not and I was able to then perform a posterior levatorplasty. Posterior levatorplasty was performed by taking #1 PDS and approximating the posterior levator just caudad to coccyx to allow for a nice angulation of the rectum. I then denied the rectum full thickness and performed an end-to-end handsewn anastomosis circumferentially with a 3-0 PDS. Specimens removed from the field. (PORTION of the RECTUM)
SuperCoder Answered Wed 17th of October, 2018 06:26:48 AM

Hello Tanesha,

Thank you for your question.


Based on the provided limited documentation, there is no specific code available for posterior levatorplasty, hence, report an unlisted CPT code 45999 (Unlisted procedure, rectum) for this procedure.

Note: When reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Include one or more similar codes and compare your service to those codes to justify the claim amount you are billing. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial.


For proctoplasty, you can report CPT code 45505 (Proctoplasty; for prolapse of mucous membrane); basis your medical documentation.


Tanesha Posted Thu 18th of October, 2018 09:52:12 AM
Thank you
SuperCoder Answered Thu 18th of October, 2018 14:46:11 PM

You're welcome

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