Gastroenterology Coding Alert

Question: Our gastroenterologist circled 45130 for this note, but it doesn’t seem to fit the report to us. Can you advise?

The perineum was prepped and draped in the usual fashion. Patient suffered a rectal prolapse of the mucosa on the right side greater than the left. I placed a Lone Star retractor to evert the anus. I then marched out with the Bovie about 1 cm distal to the dentate line. I then injected 0.25 percent Marcaine with epinephrine to create a submucosal plane with a lip of mucosal layer. I used a needle tip cautery to dissect the rectal mucosa up to a level about three to four cm above the dentate line, which equaled about the amount of rectal prolapse he was having. I dissected more posteriorly on the right and the left side. Anteriorly he did not have much in the way of rectal prolapse, so I only got about one to two cm above the dentate line there. Next, I repaired the defect by repositioning the dentate line by suturing this with reefing the rectal wall circumferentially. The dentate line was repositioned in normal position.

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Answer: You’re correct in noting that 45130 (Excision of rectal procidentia, with anastomosis; perineal approach) is an inappropriate code for this service. Based on operative report for the rectal prolapse repair, your best bet is 45541 (Proctopexy [eg, for prolapse]; perineal approach).