How To Use CPT Code 45111

CPT 45111 describes the partial resection of the rectum using an abdominal approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45111?

CPT 45111 is used to describe a surgical procedure in which a partial resection of the rectum is performed using an abdominal approach. This code is typically used when the diseased portion of the rectum cannot be safely reached using an anal or transperineal approach. The procedure is commonly performed to treat conditions such as Crohn colitis or cancer of the rectum.

2. Official Description

The official description of CPT code 45111 is: ‘Proctectomy; partial resection of rectum, transabdominal approach.’

3. Procedure

1. The provider begins by making an incision into the abdomen and exploring the abdominal cavity for any signs of metastasis.
2. The small intestine is packed up and out of the way to provide better access to the rectum.
3. The provider locates the area of the tumor and proceeds to divide the colon above the rectum and the rectum below the tumor.
4. Depending on the nature and extent of the tumor, the provider may choose to rejoin the cut ends of the colon and rectum or construct a colostomy.
5. If the decision is made to reconnect the colon and rectum, the provider sutures them back together end to end, creating an uninterrupted digestive tract.
6. Alternatively, the provider may close off the rectum and bring the proximal end of the colon out through a separate incision on the abdominal wall as a colostomy.
7. After ensuring there is no bleeding and removing any instruments, the provider closes the abdominal incision in layers.

4. Qualifying circumstances

CPT 45111 is typically performed on patients with conditions such as Crohn colitis or cancer of the rectum. The procedure is done using an abdominal approach when the diseased portion of the rectum cannot be safely reached through other methods. It is important to note that the procedure should only be performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 45111

CPT code 45111 should be used when a partial resection of the rectum is performed using an abdominal approach. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure is performed using a different approach or involves a different extent of resection, a different CPT code may be more appropriate.

6. Documentation requirements

To support a claim for CPT code 45111, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the partial resection of the rectum
• Details of the procedure, including the approach used and any specific techniques employed
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 45111, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a qualified healthcare professional and documented appropriately. It is also important to follow any additional billing guidelines provided by insurance companies or other payers.

8. Historical information

CPT code 45111 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with Crohn colitis undergoes a partial resection of the rectum using an abdominal approach.
2. A patient with rectal cancer requires a partial resection of the rectum to remove the tumor.
3. A provider performs a partial resection of the rectum on a patient with a large rectal polyp.
4. A patient with a history of rectal prolapse undergoes a partial resection of the rectum to correct the condition.
5. A partial resection of the rectum is performed on a patient with a rectovaginal fistula.
6. A provider performs a partial resection of the rectum on a patient with a rectal abscess.
7. A patient with ulcerative colitis requires a partial resection of the rectum to manage the condition.
8. A provider performs a partial resection of the rectum on a patient with a rectal stricture.
9. A patient with a large rectal polyp undergoes a partial resection of the rectum to prevent further complications.
10. A provider performs a partial resection of the rectum on a patient with a rectal tumor that is causing obstruction.