How To Use CPT Code 45116

CPT 45116 describes the partial proctectomy procedure performed using a transsacral approach. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45116?

CPT 45116 is a code used to describe a specific surgical procedure known as partial proctectomy. This procedure involves the removal of a portion of the rectum and the subsequent anastomosis, or joining, of the remaining rectum to the colon. The approach used in this procedure is the transsacral approach, also known as the Kraske type. It is typically performed to treat rectal cancer.

2. Official Description

The official description of CPT code 45116 is: ‘Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type)’. This code specifically refers to the partial removal of the rectum and the anastomosis of the remaining rectum to the colon using a transsacral approach.

3. Procedure

1. The surgeon begins by making an incision in the patient’s back, specifically over the junction of the sacrum and coccyx.
2. The coccyx, or tailbone, and part of the sacrum are then removed to gain access to the rectum.
3. Tissues are dissected posteriorly, and the rectum and distal colon are prepared.
4. The surgeon makes incisions in the rectum proximally and distally, and a portion of the rectum is removed.
5. The distal end of the colon is sutured to the remaining rectal stump.
6. The fascia and subcutaneous tissue of the back are closed in layers.
7. The surgeon checks for any bleeding, removes any instruments, and finally closes the skin incisions.

4. Qualifying circumstances

CPT 45116 is performed in cases where a partial proctectomy is necessary, specifically using a transsacral approach. This procedure is typically indicated for the treatment of rectal cancer. It is important to note that the specific circumstances and patient eligibility for this procedure should be determined by the surgeon based on the individual patient’s condition and medical history.

5. When to use CPT code 45116

CPT code 45116 should be used when a partial proctectomy procedure is performed using a transsacral approach. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code. If the procedure does not meet these criteria, an alternative code may be more appropriate.

6. Documentation requirements

Documentation for CPT code 45116 should include the following information:

• Patient’s diagnosis and indication for the partial proctectomy procedure
• Details of the transsacral approach used
• Date of the procedure
• Specific details of the procedure, including any complications or additional steps taken
• Any additional relevant information or findings
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT code 45116, it is important to ensure that the procedure meets the specific criteria outlined in the official description. The procedure should be performed using a transsacral approach, and the documentation should support the use of this code. It is also important to follow any additional billing guidelines provided by the payer or relevant coding guidelines.

8. Historical information

CPT code 45116 was added to the Current Procedural Terminology system on January 1, 1990. It has not undergone any updates or changes since its addition.

9. Examples

1. A patient with rectal cancer undergoes a partial proctectomy using a transsacral approach (CPT 45116).
2. A surgeon performs a partial proctectomy with anastomosis using a transsacral approach for a patient with a large rectal polyp (CPT 45116).
3. A partial proctectomy is performed using a transsacral approach for a patient with a rectal fistula (CPT 45116).
4. A patient with a recurrent rectal tumor undergoes a partial proctectomy with anastomosis using a transsacral approach (CPT 45116).
5. A surgeon performs a partial proctectomy using a transsacral approach for a patient with a rectal abscess (CPT 45116).
6. A partial proctectomy with anastomosis is performed using a transsacral approach for a patient with a rectal stricture (CPT 45116).
7. A patient with a large rectal polyp undergoes a partial proctectomy using a transsacral approach (CPT 45116).
8. A surgeon performs a partial proctectomy with anastomosis using a transsacral approach for a patient with a rectal tumor (CPT 45116).
9. A partial proctectomy is performed using a transsacral approach for a patient with a rectal prolapse (CPT 45116).
10. A patient with a rectal abscess undergoes a partial proctectomy with anastomosis using a transsacral approach (CPT 45116).