How To Use CPT Code 45172

CPT 45172 describes the excision of a rectal tumor using a transanal approach, including the muscularis propria. 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 45172?

CPT 45172 can be used to describe the surgical procedure performed to remove a rectal tumor through the anus. The excision includes the removal of the tumor as well as the muscularis propria, which is a thin layer of muscle lining the rectum.

2. Official Description

The official description of CPT code 45172 is: ‘Excision of rectal tumor, transanal approach; including muscularis propria (i.e., full thickness).’ This code should be used when the provider performs a full thickness excision of a rectal tumor using a transanal approach.

3. Procedure

1. The provider begins by preparing the patient and administering anesthesia.
2. A digital rectal exam may be performed to assess the tumor’s location and landmarks.
3. An anoscope may be used to further examine the inner wall of the anus and rectum.
4. The provider then makes an incision in the rectum through the anus.
5. Using a transanal approach, the provider performs a full thickness excision of the tumor, including the muscularis propria.
6. Bleeding in the area is controlled, and the wound is sutured in layers as necessary.

4. Qualifying circumstances

CPT 45172 is used for patients who require the excision of a rectal tumor through a transanal approach. This code is specifically for cases where the excision includes the muscularis propria. It is important to note that CPT 45172 should not be used for tumors that do not involve the muscularis propria or for excisions performed through other approaches, such as transsacral or transcoccygeal.

5. When to use CPT code 45172

CPT code 45172 should be used when a provider performs a transanal excision of a rectal tumor that involves the muscularis propria. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 45172, the provider must document the following information:

• Patient’s diagnosis and the need for the excision of the rectal tumor
• Details of the procedure, including the transanal approach and the inclusion of the muscularis propria
• Date of the procedure
• Any additional procedures performed, such as anoscopy or digital rectal exam
• Any complications or unexpected findings during the procedure
• Details of wound closure and any additional layers of sutures
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 45172, ensure that the excision is performed through a transanal approach and includes the muscularis propria. It is important to accurately document the procedure and any additional services provided. Additionally, be aware of other codes that may be appropriate for different approaches or partial thickness excisions of rectal tumors.

8. Historical information

CPT 45172 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Examples

1. A surgeon performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with colorectal cancer.
2. A gastroenterologist performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with a benign polyp.
3. A colorectal surgeon performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal adenocarcinoma.
4. A general surgeon performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal leiomyoma.
5. A proctologist performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal neuroendocrine tumor.
6. A surgical oncologist performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal squamous cell carcinoma.
7. A colorectal surgeon performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal carcinoid tumor.
8. A gastroenterologist performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal lymphoma.
9. A general surgeon performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal gastrointestinal stromal tumor.
10. A proctologist performs a transanal excision of a rectal tumor, including the muscularis propria, for a patient with rectal melanoma.