Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a manual disimpaction of the rectum under anesthesia. How do I report the procedure that our gastroenterologist performed?

New Jersey Subscriber

Answer: In some patients, due to chronic constipation, there can be the possibility of fecal impaction wherein the person is not able to move the feces. This impaction can sometimes extend up to the sigmoid colon. This is more of a common occurrence in elderly inactive people although it is also known to occur in children and adolescents.

To clear the impacted feces, your gastroenterologist might have to perform a manual disimpaction under anesthesia. To clear the impaction, your gastroenterologist will insert a gloved lubricated finger into the rectum and gently massage around the borders of the impaction and try to clear the mass by breaking it up. He might also use the aid of an instrument instead of using the finger to breakup the mass to clear it.

To report the procedure that your gastroenterologist performed, you will have to use the CPT® code 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia).