Rectal exam with anesthesia? Consider 45990

In a particular coding scenario, 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 carried out under anesthesia). Subsequent to this he sutured the bleeding site. But the person reporting this service could not find a proper CPT code for this. How should she go about this scenario?



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 use 45990 in combination with 45300-45327 (Proctosigmoidoscopy), 46600 (anoscopy; diagnostic, with or minus collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital test with colposcopic magnification in childhood for suspected trauma).



Physician responsibility: Anorectal exam is chiefly 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 patient is provided general, spinal or epidural anesthesia and the doctor carries out a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter primarily to inspect the perineal area. An anoscope is inserted into the rectum to visualize the anal canal and distal rectum. Post removing the anoscope, a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.

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