Use 45990 for Rectal Exam with Anesthesia

In a particular case, the surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off; however the large vessel underneath was continuing to bleed (all done under anesthesia). After this he sutured the bleeding site. If you fail to find a proper CPT code for this, what should you do in this situation?

Well, the procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). According to CCI edits, you shouldn’t 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).

Physician responsibility: Anorerctal exam is primarily done by placing the patient in left lateral decubitus position. This exam is chiefly done to study anal fissures, anal fistula, anal mass and hemorrhoids. The patient is provided general, spinal or epidural anesthesia and the physician carries out a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter mainly to examine the perineal area. An ansoscope is inserted into the rectum to visualize the anal canal and distal rectum. Soon after removing the anoscope, a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.

Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/reader-questions-consider-45990-for-rectal-exam-with-anesthesia-article