How To Use CPT Code 45121

CPT 45121 describes the complete proctectomy procedure, which involves the surgical removal of the rectum and part or the entire colon or ileum. 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 45121?

CPT 45121 is used to report the complete proctectomy procedure, which is performed to remove the diseased portion of the rectum along with part or the entire colon or ileum. The provider utilizes both an abdominal and perineal approach during the surgery. Multiple biopsies of the colon tissue may also be performed to assess the extent of the disease.

2. Official Description

The official description of CPT code 45121 is: ‘Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies.’

3. Procedure

1. During the complete proctectomy procedure, the provider makes an abdominal incision to access the colon and rectum.
2. The colon and rectum are mobilized and an incision is made in the colon to obtain multiple biopsies for further evaluation.
3. The diseased rectum and a portion of or the entire colon are removed.
4. The remaining segment of the colon or ileum is pulled down closer to the anus using sutures through a perineal approach.
5. The provider ensures hemostasis and closes the incisions by suturing the layers of tissue together.

4. Qualifying circumstances

CPT 45121 is used for patients with congenital megacolon, a condition characterized by the dilation or overgrowth of a portion of the colon due to paralysis. The procedure is performed when there is a need for complete removal of the rectum and part or the entire colon or ileum. The provider must utilize both an abdominal and perineal approach and perform multiple biopsies during the procedure.

5. When to use CPT code 45121

CPT code 45121 should be used when the provider performs a complete proctectomy procedure, removing the diseased rectum and part or the entire colon or ileum. It is important to ensure that the procedure meets the specific criteria outlined in the code description, including the use of both an abdominal and perineal approach and the performance of multiple biopsies.

6. Documentation requirements

To support a claim for CPT 45121, the provider must document the following information:

• Patient’s diagnosis and the need for a complete proctectomy
• Details of the procedure, including the use of both an abdominal and perineal approach
• Documentation of multiple biopsies performed
• Date of the procedure
• Any additional relevant information or complications encountered during the surgery

7. Billing guidelines

When billing for CPT 45121, it is important to ensure that the procedure meets all the specific criteria outlined in the code description. The provider must utilize both an abdominal and perineal approach, perform multiple biopsies, and remove the diseased rectum and part or the entire colon or ileum. It is also important to follow any additional guidelines provided by payers or coding authorities.

8. Historical information

CPT 45121 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 surgeon performs a complete proctectomy procedure on a patient with congenital megacolon, removing the diseased rectum and the entire colon. Multiple biopsies are taken during the surgery.
2. A gastroenterologist utilizes both an abdominal and perineal approach to perform a complete proctectomy on a patient with congenital megacolon, removing the diseased rectum and a portion of the colon. Multiple biopsies are performed to assess the extent of the disease.
3. A colorectal surgeon performs a complete proctectomy procedure on a patient with congenital megacolon, removing the diseased rectum and the entire ileum. Multiple biopsies are taken during the surgery.
4. A pediatric surgeon utilizes both an abdominal and perineal approach to perform a complete proctectomy on a child with congenital megacolon, removing the diseased rectum and a portion of the colon. Multiple biopsies are performed to evaluate the extent of the disease.
5. An oncology surgeon performs a complete proctectomy procedure on a patient with congenital megacolon, removing the diseased rectum and the entire colon. Multiple biopsies are taken during the surgery to determine the presence of cancerous cells.
6. A general surgeon utilizes both an abdominal and perineal approach to perform a complete proctectomy on a patient with congenital megacolon, removing the diseased rectum and a portion of the colon. Multiple biopsies are performed to assess the extent of the disease and guide further treatment.
7. A pediatric gastroenterologist performs a complete proctectomy procedure on a child with congenital megacolon, removing the diseased rectum and the entire ileum. Multiple biopsies are taken during the surgery to evaluate the extent of the disease and plan appropriate follow-up care.
8. A colorectal surgeon utilizes both an abdominal and perineal approach to perform a complete proctectomy on a patient with congenital megacolon, removing the diseased rectum and a portion of the colon. Multiple biopsies are performed to assess the extent of the disease and guide the surgical approach.