Medicare Compliance & Reimbursement

Reader Questions:

Consider 45990 for Rectal Exam With Anesthesia

Question: I can't seem to find a proper CPT code for this: The surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off but the large vessel underneath was continuing to bleed (all done under anesthesia). He then sutured the bleeding site. Any suggestions? Answer: The procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). Do not report 45990 in conjunction with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma), according to CCI Edits. Physician responsibility: Anorectal exam is mainly done by placing the patient in left lateral decubitus position. This exam is mainly done to study anal fissures, anal fistula, anal mass, and hemorrhoids. The [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more