General Surgery Coding Alert

Reviewed on May 15, 2015 Coding the treatment of rectal and anal abscesses presents certain challenges because your surgeon may not use the precise language included in the CPT® code definitions. 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. 
 
Surgeons and coders can work together to alleviate any confusion in coding these procedures. Surgeons should dictate at least the top portion of their operative reports in language that matches the language of the appropriate code descriptors. Coders should work with surgeons to pinpoint the location of the abscess and the procedure that was performed. This can also be difficult says M. Trayser Dunaway MD a general surgeon in private practice in Camden S.C.: "The problem is that 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 surgeons describe the anatomy. As a result five surgeons can dictate five entirely different descriptions about the same procedure."
 
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.
Rectal I&D (45000-45020)
One major difference between the rectal I&D codes and the anal I&D codes, Dunaway says, 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. "Speaking as a surgeon who's been draining these things for years I had never considered why perirectal abscess codes would be found in the anal section. I think that most surgeons would also be puzzled unless the codes were looked at from the perspective of the surgical approach," he says. 
 
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 [...]