How To Use CPT Code 46045

CPT 46045 describes the procedure of incision and drainage of an abscess in the rectum or nearby area, performed through the anal canal under anesthesia. 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 46045?

CPT 46045 is used to describe the incision and drainage procedure performed by a healthcare provider to remove pus from an abscess in the rectum or nearby area. This procedure is carried out through the anal canal while the patient is under anesthesia.

2. Official Description

The official description of CPT code 46045 is: ‘Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia.’

3. Procedure

1. The healthcare provider prepares and anesthetizes the patient for the procedure.
2. Using appropriate instruments, the provider accesses the abscess area through the anal canal.
3. The provider identifies the abscess and makes an incision in the affected area, which may be on the muscular part of the internal and external sphincter, the mucosal membrane, or the intramural area.
4. Purulent material or pus is drained out from the abscess.
5. After complete drainage, the provider controls any bleeding and irrigates the area with antibiotics to prevent infection.

4. Qualifying circumstances

CPT 46045 is performed when there is an abscess in the rectum or nearby area that requires drainage. The patient must be appropriately prepped and anesthetized for the procedure. The abscess can be located in the intramural, intramuscular, or submucosal layers. The procedure is typically performed transanally, through the anus.

5. When to use CPT code 46045

CPT code 46045 should be used when a healthcare provider performs the incision and drainage procedure for an abscess in the rectum or nearby area through the anal canal. It is important to note that this code is specific to procedures performed under anesthesia.

6. Documentation requirements

To support a claim for CPT 46045, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of an abscess
• Details of the procedure, including the location of the abscess and the layers involved
• Date of the procedure
• Start and end time of the procedure
• Description of the incision and drainage process
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46045, ensure that the procedure is performed through the anal canal under anesthesia. It is important to follow the specific guidelines for reporting this code and any associated modifiers. Additionally, consider any relevant bundling or unbundling rules when reporting this procedure.

8. Historical information

CPT 46045 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider performs an incision and drainage procedure through the anal canal to remove pus from an intramural abscess in the rectum.
2. Under anesthesia, a provider makes an incision in the mucosal membrane to drain an abscess located near the rectum.
3. A patient undergoes a transanal incision and drainage procedure for the removal of pus from an intramuscular abscess.
4. A healthcare provider performs an incision and drainage procedure on a submucosal abscess in the rectum, accessing it through the anal canal.
5. Under anesthesia, a provider drains an abscess in the rectum and performs anoplasty to repair a fistula.
6. A patient undergoes an incision and drainage procedure for a perianal abscess, performed through the anal canal.
7. A healthcare provider makes an incision in the intramural area to drain an abscess in the rectum, with the patient under anesthesia.
8. Under anesthesia, a provider drains an abscess located near the rectum, accessing it through the anal canal.
9. A patient undergoes a transanal incision and drainage procedure for the removal of pus from an intramuscular abscess.
10. A healthcare provider performs an incision and drainage procedure on a submucosal abscess in the rectum, accessing it through the anal canal.