Internal Medicine Coding Alert

Question: I've heard about the Secca procedure being utilized as a treatment for fecal incontinence. What CPT® code should I use to describe this procedure, and what are the guidelines around it?

North Carolina Subscriber

Answer: The Secca procedure is a transanal radiofrequency therapy for treatment of fecal incontinence (787.60-787.63). It uses radiofrequency energy delivered to the sphincteric complex of the anal canal to create discrete thermal lesions. These lesions heal over several months, with the tissue contracting, changing the tone of the tissue and improving continence.

Usually, a gastroenterologist or surgeon would perform the Secca procedure on an outpatient basis using conscious sedation and a local anesthetic. You will not find a specific CPT® code describing this procedure. It is likely that a practice would use 46999 (Unlisted procedure, anus) to report it. However, in 2004, CMS created a specific HCPCS code for this procedure when performed on Medicare patients in outpatient facilities: C9716 (Creations of thermal anal lesions by radiofrequency energy).