Gastroenterology Coding Alert

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?

Tennessee Subscriber

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, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), 57410 (Pelvic examination under anesthesia [other than local]), and 99170 (Anogenital examination,  magnified, in childhood for suspected trauma, including image recording when performed), 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 given general, spinal or epidural anesthesia and the physician performs a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter mainly to examine the perineal area. An ansoscope is inserted into the rectum to visualize the anal canal and distal rectum. After removing the anoscope a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.