How To Use CPT Code 45499

CPT 45499 describes an unlisted laparoscopy procedure performed on the rectum. 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 45499?

CPT 45499 is used to report a laparoscopic procedure on the rectum that does not have a specific code. This code is used when the provider performs a laparoscopic procedure on the rectum that is not represented by any of the standard and active CPT codes available.

2. Official Description

The official description of CPT code 45499 is: ‘Unlisted laparoscopy procedure, rectum.’

3. Procedure

1. The provider makes several incisions in the abdomen and inflates it with carbon dioxide for better exposure.
2. A scope is inserted through one of the incisions to examine the abdomen, while other incisions are used for inserting instruments.
3. Ports are placed to keep the incisions open and are removed at the conclusion of the procedure.
4. The small incisions are closed with staples or sutures.

4. Qualifying circumstances

CPT 45499 is used when there is no specific code available to describe the laparoscopic procedure performed on the rectum. It is important to note that CPT guidelines instruct not to choose a code that merely approximates the service provided. Instead, the unlisted procedure code should be used when no specific procedure or service code exists.

5. When to use CPT code 45499

CPT code 45499 should be used when the provider performs a laparoscopic procedure on the rectum that does not have a specific code. It is important to ensure that there is no other appropriate code available before reporting an unlisted procedure code.

6. Documentation requirements

To support a claim for CPT 45499, the provider should include a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. The cover letter should also include one or more similar codes and compare the service to those codes to justify the claim amount. Additionally, operative notes or other relevant documentation should be included to strengthen the claim and avoid a possible denial.

7. Billing guidelines

When billing for CPT 45499, it is important to submit a cover letter explaining the reason for using the unlisted code. The cover letter should compare the service to similar codes and provide supporting documentation. It is also important to follow any specific billing guidelines provided by the payer.

8. Historical information

CPT 45499 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a laparoscopic procedure on the rectum to remove a benign tumor.
2. A patient undergoes a laparoscopic procedure on the rectum for the treatment of rectal prolapse.
3. A provider performs a laparoscopic procedure on the rectum to repair a rectovaginal fistula.
4. A patient undergoes a laparoscopic procedure on the rectum for the treatment of rectal cancer.
5. A provider performs a laparoscopic procedure on the rectum to address complications from diverticulitis.
6. A patient undergoes a laparoscopic procedure on the rectum for the treatment of inflammatory bowel disease.
7. A provider performs a laparoscopic procedure on the rectum to address complications from radiation therapy.
8. A patient undergoes a laparoscopic procedure on the rectum for the treatment of rectal strictures.
9. A provider performs a laparoscopic procedure on the rectum to address complications from trauma.
10. A patient undergoes a laparoscopic procedure on the rectum for the treatment of rectal polyps.