How To Use CPT Code 45990

CPT 45990 is a diagnostic anorectal examination requiring anesthesia; this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 45990?

CPT 45990 is a medical code used to describe a diagnostic anorectal examination that requires anesthesia. This procedure is performed by a healthcare provider to examine the anus and rectum of a patient under general, spinal, or epidural anesthesia. The code is used by medical coders and billers to accurately document and bill for this specific procedure.

2. 45990 CPT code description

The official description of CPT code 45990 is: “Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic.”

3. Procedure

The 45990 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized using general, spinal, or epidural anesthesia.
2. The provider uses fingers or retractors to expand the anal canal and inspects the anorectal area for any disease.
3. A pelvic examination may be completed if necessary.
4. An anoscope may be inserted to visualize the anal canal and rectum, and a sigmoidoscope may be used to see the sigmoid colon and rectal lumen when necessary.
5. A separately reportable minor procedure may be performed if necessary, most commonly for hemorrhoids, mass, or fissure repair.
6. After completion of the diagnostic procedure, the area may be irrigated with antibiotics.

4. Qualifying circumstances

Patients eligible to receive CPT code 45990 services are those who require a diagnostic anorectal examination under anesthesia due to factors such as severe pain, inability to tolerate the examination without anesthesia, or the presence of a complex anorectal condition that necessitates a more thorough examination. The healthcare provider must determine the necessity of using anesthesia based on the patient’s medical history, symptoms, and physical examination findings.

5. When to use CPT code 45990

It is appropriate to bill the 45990 CPT code when a diagnostic anorectal examination is performed under general, spinal, or epidural anesthesia. This code should be used when the patient’s condition or symptoms warrant a more in-depth examination that cannot be performed without anesthesia. The decision to use anesthesia should be based on the healthcare provider’s clinical judgment and the patient’s specific needs.

6. Documentation requirements

To support a claim for CPT 45990, the following information should be documented in the patient’s medical record:

• Indication for the diagnostic anorectal examination, including the patient’s symptoms and medical history.
• Reason for using anesthesia during the examination, such as severe pain or inability to tolerate the examination without anesthesia.
• Type of anesthesia used (general, spinal, or epidural).
• Details of the examination, including findings and any separately reportable minor procedures performed.
• Post-procedure care, including the use of antibiotics if applicable.

7. Billing guidelines

When billing for CPT code 45990, it is essential to follow the specific guidelines and rules set forth by the payer. Some general tips for billing this code include:

• Ensure that the documentation supports the use of anesthesia during the diagnostic anorectal examination.
• Do not report CPT 45990 in conjunction with codes 45300-45327, 46600, 57410, or 99170, as these codes represent similar or related procedures.
• Verify the payer’s specific requirements for billing CPT 45990, as some payers may have additional guidelines or restrictions.

8. Historical information

CPT 45990 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates to the code since its addition.

9. Similar codes to CPT 45990

Five similar codes to CPT 45990 and how they differentiate from CPT 45990 are:

1. CPT 45300: This code represents a proctosigmoidoscopy, which is a more limited examination of the rectum and sigmoid colon without the use of anesthesia.
2. CPT 46600: This code is for an anoscopy, which is a diagnostic examination of the anal canal without the use of anesthesia.
3. CPT 57410: This code describes a pelvic examination under anesthesia, which focuses on the pelvic organs rather than the anorectal area.
4. CPT 99170: This code is for a thermography examination of the anorectal area, which uses temperature measurements to assess the area rather than a direct visual examination.
5. CPT 45327: This code represents a colonoscopy with the removal of a foreign body, which is a more invasive procedure than a diagnostic anorectal examination.

10. Examples

Here are 10 detailed examples of CPT code 45990 procedures:

1. A patient with severe anal pain and rectal bleeding undergoes a diagnostic anorectal examination under general anesthesia, revealing a large anal fissure that requires surgical repair.
2. A patient with a history of recurrent anal abscesses undergoes a diagnostic anorectal examination under spinal anesthesia to assess the extent of the disease and plan for surgical intervention.
3. A patient with a suspected rectal mass undergoes a diagnostic anorectal examination under epidural anesthesia, during which a biopsy is taken for further evaluation.
4. A patient with severe hemorrhoids that have not responded to conservative treatment undergoes a diagnostic anorectal examination under general anesthesia, followed by rubber band ligation of the hemorrhoids.
5. A patient with a history of inflammatory bowel disease undergoes a diagnostic anorectal examination under spinal anesthesia to assess for the presence of anal fistulas or other complications.
6. A patient with chronic constipation and rectal prolapse undergoes a diagnostic anorectal examination under epidural anesthesia to evaluate the need for surgical intervention.
7. A patient with a history of sexual assault undergoes a diagnostic anorectal examination under general anesthesia to assess for injuries and collect forensic evidence.
8. A patient with a suspected rectal foreign body undergoes a diagnostic anorectal examination under spinal anesthesia, during which the foreign body is successfully removed.
9. A patient with a history of anal cancer undergoes a diagnostic anorectal examination under epidural anesthesia to assess for recurrence or complications related to previous treatment.
10. A patient with severe anal stenosis undergoes a diagnostic anorectal examination under general anesthesia to evaluate the need for surgical intervention to restore normal function.