Gastroenterology Coding Alert

When in doubt, query your providers.

When you encounter a chart for anal or rectal incision and drainage (I&D), you may face challenges in selecting the right code, since the descriptors don’t always match up with the physician’s wording in the operative reports.

Simply determining whether a procedure should be considered a rectal or anal I&D can be difficult, for example, because the I&D codes in the anus section refer to the rectum, and vice versa. Terms such as “perirectal” and “perianal” describe the general area around the rectum and anus and as such can be interpreted in many different ways. Ensure your coding is on the right track with this expert advice.

Query Your Providers

Coders should work with surgeons to pinpoint the location of the abscess and the procedure that was performed. Unfortunately, identification of the location of an anal or rectal abscess can be extremely subjective. There is a lot of variation in the anatomy itself and in how physicians describe the anatomy.

Rectal I&D and anal I&D codes include:

• 45000 (Transrectal drainage of pelvic abscess)
• 45005 (Incision and drainage of submucosal abscess rectum)
• 45020 (Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess)
• 46040 (Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure))
• 46045 (Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia)
• 46050 (Incision and drainage, perianal abscess, superficial)
• 46060 (Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton).

Pay Attention to Drainage Approach

One major difference between the rectal I&D codes and the anal I&D codes is that rectal codes are used if drainage is transrectal or performed through the rectum and anal codes are used if drainage is through the skin adjacent to the anus.

Use 45000 if the rectum wall is opened so that a pelvic abscess can be drained. Code 45005 is appropriate if an abscess between the mucosa and the muscularis in the rectum is drained through an opening in the mucosal wall of the rectum. Use 45020 when draining abscesses that have formed in deep cavities such as the supralevator, the pelvirectal cavity, or the retrorectal space.

This Is the Simplest of the Services

I&D of a superficial perianal abscess (46050), typically performed in the physician’s office, is the simplest of anal I&D procedures. Use 46040 if the abscess is perirectal and/or ischiorectal but do not use 46040 if another procedure is performed in the same anatomical region. Code 46045 is appropriate if deeper I&D is required because the abscess is submucosal or intramuscular.

Use 46060 if a fistula has formed and needs to be either cut (fistulotomy) or removed (fistulectomy) regardless of whether a seton is implanted. A seton inserted during a different procedure may be reported with 46020 (Placement of seton).

Warning: You should not report code 46020with 46060 for the same operative session. According to the Correct Coding Initiative (CCI), 46020 is bundled into 46060 and will not be reimbursed if the two codes are reported together, unless you can prove that the services were separate and distinct from one another.

Know the Rules for Subsequent Debridements

Your gastroenterologist may need to perform one or more debridements after I&D of an abscess, particularly for large cavities requiring anesthesia to repack, ensure proper continued drainage, and remove nonviable tissue.

Although these debridements are typically performed during the global period of the earlier I&D, in most cases you may be report them separately with modifier 58 (Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period).

Get A Handle on Physician Documentation

The anatomical differences among the codes can be subject to much interpretation, so physicians must become more familiar with CPT^® terminology and use it to describe accurately what was performed. As the coder reviewing the claim form or selecting the code, if you have not talked with the surgeon and you’re unfamiliar with the procedure and/or the appropriate medical terminology, a coding mix-up may result.

As with most coding conundrums, communication is key. If there is a disconnect between the physicians and the coders, it’s a good idea to set up a session where both sides can share information that will help the other.