How To Use CPT Code 0184T

CPT 0184T describes the excision of a rectal tumor using a transanal endoscopic microsurgical approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0184T?

CPT 0184T can be used to describe the excision of a rectal tumor using a transanal endoscopic microsurgical approach. This code is used when the provider identifies and removes a rectal tumor using a proctoscope, while aiming to leave the anus unharmed.

2. Official Description

The official description of CPT code 0184T is: ‘Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, full thickness).’

3. Procedure

1. The provider inserts a proctoscope to visualize and examine the rectum and anus.
2. High flow carbon dioxide is used to insufflate the lumen of the rectum.
3. The provider dissects the tumor from its lower edge, ensuring a macroscopic margin of 5 mm from the tumor.
4. Full-thickness resection is performed circumferentially, while safeguarding the normal surrounding mucosa.
5. The rectum is irrigated with antimicrobial agents and the rectal wall is sutured.
6. The provider examines the rectum through the proctoscope to ensure appropriate closure.

4. Qualifying circumstances

Patients eligible for CPT 0184T are those requiring the excision of a rectal tumor using a transanal endoscopic microsurgical approach. This code is specifically for cases where the provider aims to leave the anus unharmed. It should not be reported in conjunction with other codes for non-endoscopic excision of rectal tumors or certain other procedures.

5. When to use CPT code 0184T

CPT code 0184T should be used when the provider performs an excision of a rectal tumor using a transanal endoscopic microsurgical approach, including full-thickness removal. It should not be used for other types of excisions or in conjunction with certain other codes.

6. Documentation requirements

To support a claim for CPT 0184T, the provider must document the following information:

• Patient’s diagnosis necessitating the excision of the rectal tumor
• Use of the transanal endoscopic microsurgical approach
• Date and details of the procedure, including the use of a proctoscope, insufflation of carbon dioxide, dissection of the tumor, full-thickness resection, irrigation, suturing, and examination for appropriate closure
• Any additional relevant information or findings
• Provider’s signature

7. Billing guidelines

When billing for CPT 0184T, ensure that the procedure meets the criteria for a transanal endoscopic microsurgical approach and includes full-thickness removal of the rectal tumor. Be aware of any restrictions on reporting this code with other related codes. Follow appropriate coding guidelines and modifiers as necessary.

8. Historical information

CPT 0184T was added to the Current Procedural Terminology system on January 1, 2009. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a transanal endoscopic microsurgical excision of a rectal tumor, ensuring full-thickness removal while preserving the anus.
2. Using a proctoscope, a provider identifies and removes a rectal tumor through a transanal endoscopic microsurgical approach, aiming to leave the anus unharmed.
3. During a procedure, a provider utilizes a transanal endoscopic microsurgical approach to excise a rectal tumor, performing full-thickness removal and safeguarding the surrounding mucosa.
4. A rectal tumor is successfully excised using a transanal endoscopic microsurgical approach, with the provider ensuring full-thickness resection and appropriate closure of the rectum.
5. Using a proctoscope, a provider performs a transanal endoscopic microsurgical excision of a rectal tumor, following the necessary steps to preserve the anus and achieve full-thickness removal.
6. During a procedure, a provider utilizes a transanal endoscopic microsurgical approach to remove a rectal tumor, taking care to leave the anus unharmed and performing full-thickness resection.
7. A rectal tumor is excised using a transanal endoscopic microsurgical approach, with the provider ensuring full-thickness removal and meticulous closure of the rectal wall.
8. Using a proctoscope, a provider performs a transanal endoscopic microsurgical excision of a rectal tumor, aiming to leave the anus intact and achieving full-thickness resection.
9. During a procedure, a provider utilizes a transanal endoscopic microsurgical approach to remove a rectal tumor, ensuring full-thickness resection and thorough examination for appropriate closure.
10. A rectal tumor is successfully excised using a transanal endoscopic microsurgical approach, with the provider preserving the anus and performing full-thickness removal.