How To Use CPT Code 45825

CPT 45825 describes the closure of a rectourethral fistula with the creation of a colostomy. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45825?

CPT 45825 is used to describe the surgical procedure performed to close a rectourethral fistula and create a colostomy. This code is used when the provider makes an incision in the abdomen to access the abnormal opening between the rectum and the urethra. The procedure involves closing the defect in the rectum with sutures and creating a colostomy with the sigmoid colon on the surface of the abdomen.

2. Official Description

The official description of CPT code 45825 is: ‘Closure of rectourethral fistula; with colostomy.’

3. Procedure

1. The provider makes an incision in the abdomen to access the rectourethral fistula.
2. Retractors are placed to expose the rectum.
3. The provider mobilizes the rectum and colon to gain access to the urethra.
4. The abnormal passage between the rectum and the urethra is dissected and prepared for closure.
5. The provider closes the defect in the rectum with sutures.
6. A colostomy is created with the sigmoid colon on the surface of the abdomen.
7. The operative site is irrigated and the incision is closed in layers with sutures.

4. Qualifying circumstances

CPT 45825 is performed when there is a rectourethral fistula that needs to be closed. This procedure is typically done for patients who have an abnormal opening between the rectum and the urethra. It is important to note that this code is specifically for cases where a colostomy is created along with the closure of the fistula.

5. When to use CPT code 45825

CPT code 45825 should be used when the provider performs the closure of a rectourethral fistula and creates a colostomy. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the closure of the fistula is performed without a colostomy, a different code should be used.

6. Documentation requirements

To support a claim for CPT 45825, the provider must document the following information:

• Patient’s diagnosis and the presence of a rectourethral fistula
• Details of the procedure performed, including the creation of a colostomy
• Date of the procedure
• Any additional relevant information or complications encountered during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45825, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the closure of the rectourethral fistula and the creation of a colostomy. Be aware of any additional guidelines or modifiers that may be required for proper billing.

8. Historical information

CPT 45825 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes over the years, including being added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes CPT 45825 for the closure of a rectourethral fistula and the creation of a colostomy.
2. A provider performs CPT 45825 to repair a rectourethral fistula and create a colostomy in a patient with a history of pelvic trauma.
3. CPT 45825 is used for a patient with a congenital rectourethral fistula who requires surgical intervention and the creation of a colostomy.
4. A provider performs CPT 45825 to close a rectourethral fistula and create a colostomy in a patient with a history of radiation therapy.
5. A patient with a rectourethral fistula undergoes CPT 45825 for the closure of the fistula and the creation of a colostomy to allow for healing.
6. CPT 45825 is used for a patient with a rectourethral fistula resulting from a previous surgical procedure who requires closure of the fistula and the creation of a colostomy.
7. A provider performs CPT 45825 to repair a rectourethral fistula and create a colostomy in a patient with inflammatory bowel disease.
8. CPT 45825 is used for a patient with a rectourethral fistula and fecal incontinence who requires surgical intervention and the creation of a colostomy.
9. A patient with a rectourethral fistula undergoes CPT 45825 for the closure of the fistula and the creation of a colostomy to improve their quality of life.
10. CPT 45825 is used for a patient with a rectourethral fistula and recurrent urinary tract infections who requires surgical intervention and the creation of a colostomy.