How To Use CPT Code 45915

CPT 45915 describes the removal of a foreign body or fecal impaction from the rectal area under anesthesia. 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 45915?

CPT 45915 can be used to describe the procedure in which a healthcare provider removes a foreign body or fecal impaction from the rectal area while the patient is under anesthesia. This code is used when the provider manually removes the impaction by inserting a gloved, lubricated finger and massaging around the edges of the impaction to break it up. The provider may also use a disimpaction tool to facilitate the removal.

2. Official Description

The official description of CPT code 45915 is: ‘Removal of fecal impaction or foreign body (separate procedure) under anesthesia.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider inserts a gloved, lubricated finger into the rectal area and massages around the edges of the impaction to break it up.
3. If necessary, the provider may use a disimpaction tool to facilitate the removal of the impaction or foreign body.

4. Qualifying circumstances

CPT 45915 is used when a patient has a foreign body or fecal impaction in the rectal area that requires manual removal under anesthesia. This procedure is typically performed on patients who have chronic constipation or have swallowed a foreign object that has become lodged in the gastrointestinal tract.

5. When to use CPT code 45915

CPT code 45915 should be used when a healthcare provider performs the separate procedure of removing a fecal impaction or foreign body from the rectal area under anesthesia. It should not be reported if the provider performs any other major procedure in the same location and session.

6. Documentation requirements

To support a claim for CPT 45915, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of a fecal impaction or foreign body
• Details of the procedure, including the use of anesthesia
• Any tools or techniques used during the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45915, ensure that the procedure is performed as a separate procedure and under anesthesia. Do not report this code if the provider performs any other major procedure in the same location and session. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 45915 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider removes a fecal impaction from a patient’s rectal area under anesthesia.
2. A patient presents with a foreign body in their rectal area, and the provider performs a separate procedure to remove it while the patient is under anesthesia.
3. A patient with chronic constipation requires the manual removal of a fecal impaction under anesthesia.
4. A healthcare provider discovers a foreign body in a patient’s rectal area and performs a separate procedure to remove it under anesthesia.
5. A patient swallows a foreign object that becomes lodged in their gastrointestinal tract, and the provider performs a separate procedure to remove it from the rectal area under anesthesia.
6. A healthcare provider performs a separate procedure to remove a fecal impaction from a patient’s rectal area, using a disimpaction tool to facilitate the removal.
7. A patient with chronic constipation requires the manual removal of a fecal impaction under anesthesia, with the provider using a gloved, lubricated finger to break up the impaction.
8. A healthcare provider removes a foreign body from a patient’s rectal area under anesthesia, using a combination of manual manipulation and a disimpaction tool.
9. A patient presents with a fecal impaction that requires manual removal under anesthesia, and the provider successfully breaks up the impaction using a gloved, lubricated finger.
10. A healthcare provider performs a separate procedure to remove a foreign body from a patient’s rectal area under anesthesia, ensuring the patient’s comfort and safety throughout the procedure.