# Help with Rectal Tear, Please!!!



## Jody Mortensen (Dec 16, 2009)

A patient presents to ER with rectal pain/bleeding due to rectal laceration from straining caused by constipation.  Patient taken to OR for repair of laceration extending into rectum but not into peritoneal space.  Repair done by suturing done via rectum.  I have 2 questions:1.) I am not clear on the CPT code for the repair, I can only find 45562 which seems to be more involved than the procedure performed.  The Ingenix book states the procedure decribed my vary depending on the nature & extent of the injury but it has a high RVU value, I believe we found it to have 17.  So, we were thinking of using 45562 with a 52 modifier?  Any thoughts on this?  2.) I'm not clear on the diagnosis coding for this do I go with an injury dx code 863.45 or the 569.42/569.3. I'm thinking the 863 code but not sure.  Any direction, help would be appreciated.

                                        Thank you
                                                 Jody


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## njohnson0476 (Dec 16, 2009)

This is a good one.  I wonder if the repair codes would work?  The 13131 does include genitalia.  Not sure if the rectum would fall into that category.  Have you reviewed any of those codes?


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## elenax (Dec 17, 2009)

I would go with what you coded...45562-52/ or with an unlisted code(which I avoid using)...also agree with the 863.45 and 569.42...hope this helps...I see what you said about the description and why you are using the 52 modifier...


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## Jody Mortensen (Dec 17, 2009)

*Thank you*

Thank you for your responses, I feel good about going with 45562-52.


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