Gastroenterology Coding Alert

Question: My gastroenterologist performed an anal dilation in the office. The CPT only lists 45905 using anesthesia other than local. He advises he did not use any anesthesia or local numbing. How should this be coded?

Maryland Subscriber

Answer: If the procedure was not extensive and your gastroenterologist performed no other procedures, you may include it as part of the E/M service for that encounter. Another option would be to code 45905 (Dilation of anal sphincter [separate procedure] under anesthesia other than local) and append modifier 52 (Reduced services). However, you'd need to be prepared to defend the use of that code with solid documentation since not even local anesthetic was used.

If your gastroenterologist performed the dilation to perform another procedure, take care. Anal dilation is explicitly part of some procedure codes, such as 46940 (Curettage or cautery of anal fissure, including dilation of anal sphincter [separate procedure]; initial).