General Surgery Coding Alert

Question: Our surgeon has recently begun to perform the STARR procedure, and I am unsure of how to code for this. The surgeon suggested 45123. I have reservations about that code because it is a perineal approach and the STARR procedure is through the anus.-Any suggestions?

Utah Subscriber

Answer: The STARR (stapled transanal rectal resection) procedure is a recently developed technique to treat obstructed defecation syndrome (ODS). Using circular, surgical staplers similar to those used during hemorrhoidopexy (46947, Hemorrhoidopexy [e.g., for prolapsing internal hemorrhoids] by stapling), the surgeon simultaneously removes excess tissue from and resects the lower rectum, which reduces the anatomical defects that can cause ODS. The procedure occurs via an anal approach, requires no external incisions and leaves no visible scars.

As you suggest, 45123 (Proctectomy, partial, without anastomosis, perineal approach) is not appropriate because 45123 describes a perineal approach and also does not take into account the unique resection method.

CPT does not list a dedicated code to report the STARR procedure. Therefore, your best code choice is 46999 (Unlisted procedure, anus). Although filing a claim with an unlisted-procedure code will mean extra work, correct coding guidelines demand that you use a code that most accurately describes the service the physician provides, not a code that is "close enough" but actually represents a different service.

When submitting an unlisted-procedure claim, you should file a "paper" (or manual) claim with the complete operative note and a cover letter that explains in simple, straightforward language exactly what the physician did. Because there are no standard fees for unlisted-procedure codes, you should suggest a reimbursement based on a similar procedure, such as 46947. To justify your reimbursement suggestion, provide the payer with a comparison between the STARR procedure and hemorrhoidopexy (more or less difficult, etc.), for instance, based on the physician's clinical judgment and documentation.

Include in box 19 of the CMS-1500 (or electronic equivalent) a short description of the unlisted service and indicate that documentation is included.

Some payers require an electronic claim as proof of "timely filing." For these payers, file the claim electronically and then submit paper documentation with a note stating, "This is not a duplicate claim. This documentation supports an electronic claim."