How To Use CPT Code 45400

CPT 45400 describes the laparoscopic surgical procedure known as proctopexy, which is performed to treat rectal prolapse. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45400?

CPT 45400 is a code used to describe a laparoscopic surgical procedure called proctopexy. This procedure is performed to treat rectal prolapse, which occurs when the rectum droops due to laxity in the ligaments holding it in place. The provider uses sutures and mesh to fixate the rectum to the sacrum, providing support and preventing further prolapse.

2. Official Description

The official description of CPT code 45400 is: ‘Laparoscopy, surgical; proctopexy (for prolapse).’ This code is specifically for the laparoscopic approach to performing a proctopexy procedure. It is important to note that for an open procedure, different codes should be used (45540 for abdominal approach and 45541 for perineal approach).

3. Procedure

1. When performing a laparoscopic proctopexy, the provider begins by making a small incision at the umbilicus (navel) and inserting a laparoscope, which is a camera attached to a long, thin instrument.
2. Additional small incisions are made around the abdomen to introduce other instruments needed for the procedure.
3. The provider insufflates the abdomen with carbon dioxide gas to create a working and viewing space by elevating the abdominal wall above the internal organs.
4. The complete length of the rectum is mobilized, or freed, down to the pelvic floor.
5. A polypropylene mesh is used to attach the rectum to the sacrum, and the provider sutures it on both sides of the rectum for added support.
6. Once the procedure is complete, the laparoscope and other instruments are removed, and the incision sites are closed with sutures.

4. Qualifying circumstances

CPT 45400 is used for patients who have rectal prolapse and require surgical intervention. The procedure is performed laparoscopically by a qualified provider. It is important to note that this code specifically applies to proctopexy procedures and should not be used for other laparoscopic rectal surgeries.

5. When to use CPT code 45400

CPT code 45400 should be used when a laparoscopic proctopexy procedure is performed to treat rectal prolapse. It is important to ensure that the procedure meets the specific criteria outlined in the code description and that the provider uses the laparoscopic approach. If an open procedure is performed, different codes should be used.

6. Documentation requirements

When reporting CPT code 45400, the provider must document the following information:

• Patient’s diagnosis of rectal prolapse
• Description of the laparoscopic proctopexy procedure performed
• Date of the procedure
• Details of the specific steps taken during the procedure
• Any complications or additional procedures performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 45400, it is important to ensure that the procedure performed meets the criteria outlined in the code description. The laparoscopic approach should be clearly documented in the medical record. It is also important to follow any specific billing guidelines provided by insurance carriers or payers. Additionally, it is crucial to review any bundling or unbundling rules that may apply to this procedure.

8. Historical information

CPT code 45400 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 prolapse undergoes a laparoscopic proctopexy procedure to fixate the rectum to the sacrum.
2. A provider performs a laparoscopic proctopexy on a patient with recurrent rectal prolapse.
3. A laparoscopic proctopexy is performed on a patient with rectal prolapse and a history of previous abdominal surgeries.
4. A provider performs a laparoscopic proctopexy on a patient with rectal prolapse and concurrent pelvic organ prolapse.
5. A laparoscopic proctopexy is performed on a patient with rectal prolapse and symptoms of fecal incontinence.
6. A provider performs a laparoscopic proctopexy on a patient with rectal prolapse and chronic constipation.
7. A laparoscopic proctopexy is performed on a patient with rectal prolapse and a history of pelvic floor dysfunction.
8. A provider performs a laparoscopic proctopexy on a patient with rectal prolapse and a history of previous unsuccessful non-surgical treatments.
9. A laparoscopic proctopexy is performed on a patient with rectal prolapse and symptoms of rectal bleeding.
10. A provider performs a laparoscopic proctopexy on a patient with rectal prolapse and symptoms of rectal pain and discomfort.