How To Use CPT Code 45110

CPT 45110 describes the complete excision of the rectum, combined abdominoperineal, with colostomy. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45110?

CPT 45110 can be used to describe the complete excision of the rectum, combined abdominoperineal, with colostomy. This code is used when the provider removes the entire rectum along with a portion of the lower colon and the anal sphincter via an abdominoperineal approach. The procedure is typically performed to treat Crohn colitis or cancer of the colon and rectum.

2. Official Description

The official description of CPT code 45110 is: ‘Proctectomy; complete, combined abdominoperineal, with colostomy.’ This code is used for the complete excision of the rectum, combined abdominoperineal, with the creation of a colostomy.

3. Procedure

1. The provider performs a digital rectal examination to assess the anal sphincter.
2. A pursestring suture is used to close the anus.
3. An abdominal incision is made, and the provider examines the abdomen for metastatic disease.
4. The small intestine is packed up out of the way.
5. The proximal sigmoid is divided, typically with a stapler, and the cut end is brought out to form a colostomy.
6. The cut edges of the rectum are closed with staples or sutures.
7. The abdomen and pelvis are irrigated.
8. Tubes may be left in place for further drainage.
9. The fascia and subcutaneous tissue are closed in layers.
10. The skin is closed, and the stoma for the colostomy is fashioned.
11. If necessary, a second provider may perform the perineal portion of the procedure.
12. In the perineal portion, an incision is made in the perineal body to include the sphincter muscle.
13. The rectum is removed, and the pelvis is irrigated.
14. The floor of the pelvis is closed.
15. The perineal incision is closed.

4. Qualifying circumstances

Patients eligible for CPT 45110 are those with Crohn colitis or cancer of the colon and rectum that require complete excision of the rectum and the creation of a colostomy. The procedure is typically performed by a provider using an abdominoperineal approach.

5. When to use CPT code 45110

CPT code 45110 should be used when the provider performs a complete excision of the rectum, combined abdominoperineal, with the creation of a colostomy. This code is appropriate for cases involving Crohn colitis or cancer of the colon and rectum.

6. Documentation requirements

To support a claim for CPT 45110, the provider must document the following information:

• Patient’s diagnosis of Crohn colitis or cancer of the colon and rectum
• Description of the procedure performed, including the complete excision of the rectum and the creation of a colostomy
• Date of the procedure
• Details of the surgical approach used
• Any additional procedures performed, such as perineal incision and closure
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45110, ensure that the procedure performed meets the criteria for complete excision of the rectum, combined abdominoperineal, with colostomy. Use the appropriate CPT code based on the specific procedure performed. It is important to follow the specific guidelines provided by the payer for accurate billing and reimbursement.

8. Historical information

CPT 45110 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added under the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with Crohn colitis undergoes a complete excision of the rectum, combined abdominoperineal, with colostomy.
2. A patient with colon cancer requires a complete excision of the rectum, combined abdominoperineal, with colostomy.
3. A provider performs a complete excision of the rectum, combined abdominoperineal, with colostomy for a patient with rectal cancer.
4. A patient with recurrent Crohn colitis undergoes a complete excision of the rectum, combined abdominoperineal, with colostomy.
5. A provider performs a complete excision of the rectum, combined abdominoperineal, with colostomy for a patient with a large rectal polyp.
6. A patient with advanced colon cancer requires a complete excision of the rectum, combined abdominoperineal, with colostomy.
7. A provider performs a complete excision of the rectum, combined abdominoperineal, with colostomy for a patient with a rectal fistula.
8. A patient with Crohn colitis and severe rectal bleeding undergoes a complete excision of the rectum, combined abdominoperineal, with colostomy.
9. A provider performs a complete excision of the rectum, combined abdominoperineal, with colostomy for a patient with a rectal abscess.