How To Use CPT Code 45563

CPT 45563 describes the exploration, repair, and presacral drainage for rectal injury, along with the creation of a colostomy. 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 45563?

CPT 45563 can be used to describe a surgical procedure that involves exploring the rectum and nearby area for any injury, repairing the injury if found, draining any abscess or fluid in the presacral area, and creating a colostomy with the sigmoid colon. This code is used when the provider performs these procedures to treat a rectal injury.

2. Official Description

The official description of CPT code 45563 is: ‘Exploration, repair, and presacral drainage for rectal injury; with colostomy.’

3. Procedure

1. The provider makes an incision in the lower abdomen area to access the rectum and nearby structures.
2. He explores the rectum and nearby area to identify any injury.
3. If a rectal injury is found, the provider repairs it using sutures.
4. The provider then creates a colostomy by bringing one end of the sigmoid colon out through an incision on the abdominal wall.
5. If there is any abscess or fluid in the presacral area, the provider drains it through a separate incision.
6. After completing the necessary repairs and drainage, the provider irrigates the operative site and closes the incisions with sutures.

4. Qualifying circumstances

CPT 45563 is used when a patient has a rectal injury that requires exploration, repair, and presacral drainage. The procedure is performed by a qualified provider who has the necessary skills and training to perform these surgical interventions. The patient may have experienced trauma or other conditions that have caused the rectal injury.

5. When to use CPT code 45563

CPT code 45563 should be used when a provider performs the exploration, repair, and presacral drainage for a rectal injury, along with the creation of a colostomy. This code is appropriate when all of these procedures are performed during the same surgical session.

6. Documentation requirements

To support a claim for CPT 45563, the provider must document the following information:

• Patient’s diagnosis indicating the rectal injury
• Details of the exploration, repair, and presacral drainage procedures
• Description of the colostomy creation
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Operative notes including the specific techniques used
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45563, ensure that the procedure includes the exploration, repair, and presacral drainage for a rectal injury, along with the creation of a colostomy. It is important to use the appropriate CPT code based on the specific procedures performed. Additionally, follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 45563 was added to the Current Procedural Terminology system on January 1, 1995. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A patient sustains a rectal injury due to a traumatic accident. The provider performs exploration, repair, and presacral drainage for the injury, along with the creation of a colostomy.
2. A patient presents with a rectal injury caused by a medical condition. The provider performs the necessary procedures to explore, repair, and drain the injury, and also creates a colostomy.
3. A patient undergoes surgery for a rectal injury resulting from a surgical complication. The provider performs exploration, repair, and presacral drainage, and creates a colostomy during the same procedure.
4. A patient with a rectal injury due to a chronic condition requires surgical intervention. The provider performs the exploration, repair, and drainage procedures, and also creates a colostomy to aid in the healing process.
5. A patient experiences a rectal injury as a result of a gastrointestinal disorder. The provider performs the necessary procedures to explore, repair, and drain the injury, and creates a colostomy to facilitate recovery.