How To Use CPT Code 45402

CPT 45402 describes a laparoscopic surgical procedure known as proctopexy with sigmoid resection. 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 45402?

CPT 45402 is a code used to describe a laparoscopic surgical procedure called proctopexy with sigmoid resection. This procedure involves the treatment of rectal prolapse and the removal of part of the sigmoid colon. The provider repairs both the rectum and sigmoid colon using sutures and mesh.

2. Official Description

The official description of CPT code 45402 is: ‘Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection.’ This code is used for laparoscopic surgical procedures that involve the fixation of the rectum using mesh or sutures, along with the resection of the sigmoid colon.

3. Procedure

1. The provider begins by making a small incision into the abdomen, typically at the umbilicus (navel).
2. A laparoscope, which is a camera attached to an instrument, is inserted through a trocar into the abdomen to provide visualization.
3. Additional incisions are made around the abdomen to introduce other surgical instruments.
4. The abdomen is insufflated with carbon dioxide gas to create a working and viewing space.
5. The provider resects the redundant segment of the sigmoid colon and connects it directly with the rectum by suturing them together.
6. The provider then mobilizes the complete length of the rectum down to the pelvic floor and attaches the rectum to the sacrum using a polypropylene mesh, which is sutured on both sides of the rectum.
7. Finally, the laparoscope and trocars are removed, and the incision sites are closed with sutures.

4. Qualifying circumstances

CPT 45402 is performed on patients with rectal prolapse, which occurs when the rectum droops due to laxity in the ligaments holding it. The procedure is used to fix the rectum using mesh or sutures and involves the resection of the sigmoid colon. It is important to note that this procedure is typically performed laparoscopically.

5. When to use CPT code 45402

CPT code 45402 should be used when a laparoscopic proctopexy with sigmoid resection is performed. It is important to ensure that the procedure is performed using a laparoscopic approach and involves the fixation of the rectum and resection of the sigmoid colon. If an open approach is used, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 45402, the provider must document the following information:

• Patient’s diagnosis of rectal prolapse
• Details of the laparoscopic procedure performed, including the fixation of the rectum and resection of the sigmoid colon
• Date of the procedure
• Start and end time of the procedure
• Specific techniques used during the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 45402, it is important to ensure that the procedure was performed laparoscopically and involved the fixation of the rectum and resection of the sigmoid colon. It is also important to follow any specific billing guidelines provided by the payer. Additionally, it is important to note that CPT 45402 should not be reported with other codes unless specific circumstances apply.

8. Historical information

CPT 45402 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates to the code since its addition. It is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient undergoes a laparoscopic proctopexy with sigmoid resection to treat rectal prolapse.
2. A provider performs a laparoscopic proctopexy with sigmoid resection on a patient with rectal prolapse and a redundant segment of the sigmoid colon.
3. A laparoscopic procedure is performed to fix the rectum and resect the sigmoid colon in a patient with rectal prolapse.
4. A provider uses a laparoscopic approach to perform proctopexy with sigmoid resection on a patient with rectal prolapse and laxity in the ligaments holding the rectum.
5. A laparoscopic proctopexy with sigmoid resection is performed to repair rectal prolapse and remove a segment of the sigmoid colon.
6. A patient undergoes a laparoscopic procedure to fix rectal prolapse and resect the sigmoid colon using sutures and mesh.
7. A provider performs a laparoscopic proctopexy with sigmoid resection to treat rectal prolapse and provide support to the weakened area.
8. A laparoscopic procedure is performed to repair rectal prolapse and resect the sigmoid colon, improving the patient’s condition.
9. A patient undergoes a laparoscopic proctopexy with sigmoid resection to address rectal prolapse and restore normal function.
10. A provider uses a laparoscopic approach to fix rectal prolapse and resect the sigmoid colon, providing relief to the patient.