How To Use CPT Code 45395

CPT code 45395 describes a laparoscopic surgical procedure known as proctectomy. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45395?

CPT 45395 is a code used to describe a laparoscopic surgical procedure called proctectomy. This procedure involves the complete removal of the rectum, combined with the creation of a colostomy. It is typically performed using a laparoscope, which is a camera attached to a lighted tube that allows the surgeon to visualize the abdominal or pelvic cavity.

2. Official Description

The official description of CPT code 45395 is: ‘Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy.’ This code specifically refers to the laparoscopic removal of the entire rectum, along with the creation of a colostomy, which is a surgical opening in the abdominal wall through which waste can leave the body and collect in a bag.

3. Procedure

1. The surgeon begins by making small incisions in the abdomen, typically including one at the umbilicus (belly button), through which a trocar is inserted to create a working and viewing space.
2. The abdomen is then inflated with carbon dioxide gas to elevate the abdominal wall and create a better visual field.
3. A laparoscope is inserted through one of the incisions, allowing the surgeon to visualize the abdominal or pelvic cavity.
4. Additional trocars are inserted through the other incisions to provide access for surgical instruments.
5. The sigmoid colon, which is the end of the large intestine, is prepared and pulled upward.
6. The surgeon incises the right pelvic peritoneum and dissects and ligates the inferior mesenteric artery and vein.
7. The peritoneum on both sides of the rectum is incised and the rectum is freed from adjacent structures.
8. A loop of the sigmoid colon is brought through an incision and secured with sutures to create a colostomy.
9. The rectum is then removed through an additional incision in the perineum, which is the area between the anus and the vulva in females or the anus and the scrotum in males.
10. Finally, the incisions are closed with sutures.

4. Qualifying circumstances

CPT 45395 is typically performed on patients who require the complete removal of the rectum and the creation of a colostomy. This procedure may be necessary for conditions such as rectal cancer or inflammatory bowel disease. It is important to note that CPT 45395 specifically refers to the laparoscopic approach, and an open procedure should be coded differently (use code 45110).

5. When to use CPT code 45395

CPT code 45395 should be used when a laparoscopic proctectomy with colostomy is performed. It is important to ensure that the procedure meets the specific criteria outlined in the code description, including the complete removal of the rectum and the creation of a colostomy. If the procedure is performed using an open approach, a different code should be used (code 45110).

6. Documentation requirements

To support a claim for CPT 45395, the surgeon must document the following information:

• Patient’s diagnosis necessitating the proctectomy
• Details of the laparoscopic approach, including the number and location of incisions
• Description of the steps performed during the procedure, such as the preparation of the sigmoid colon, dissection and ligation of blood vessels, and removal of the rectum
• Documentation of the creation of a colostomy
• Any additional procedures or findings during the surgery
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 45395, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The laparoscopic approach should be clearly documented, and the complete removal of the rectum and creation of a colostomy should be performed. It is also important to note that CPT code 45395 is typically an inpatient-only procedure, meaning it is not typically performed in an outpatient setting.

8. Historical information

CPT code 45395 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with rectal cancer undergoes a laparoscopic proctectomy with colostomy.
2. A patient with ulcerative colitis requires a laparoscopic proctectomy with colostomy to manage their condition.
3. A laparoscopic proctectomy with colostomy is performed on a patient with Crohn’s disease.
4. A patient with a large rectal polyp undergoes a laparoscopic proctectomy with colostomy for removal.
5. A laparoscopic proctectomy with colostomy is performed on a patient with a rectal abscess.
6. A patient with familial adenomatous polyposis requires a laparoscopic proctectomy with colostomy to prevent the development of colon cancer.
7. A laparoscopic proctectomy with colostomy is performed on a patient with radiation proctitis.
8. A patient with diverticulitis undergoes a laparoscopic proctectomy with colostomy to manage their condition.
9. A laparoscopic proctectomy with colostomy is performed on a patient with a rectovaginal fistula.