How To Use CPT Code 46060

CPT 46060 describes the procedure of incision and drainage of an ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton. 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 46060?

CPT 46060 is used to describe the incision and drainage procedure performed by a healthcare provider to treat an abscess in the rectal area. The provider may also perform a fistulectomy or fistulotomy, and may place a seton in the fistula tract. This code is used when the procedure is performed submuscularly, meaning below the muscle.

2. Official Description

The official description of CPT code 46060 is: ‘Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure and administers anesthesia.
2. The provider makes an incision in the anal sphincter to access the abscess.
3. The abscess is incised and drained, removing the purulent material or pus.
4. If there is an anal fistula present, the provider may remove it or incise it to treat the abscess within.
5. A seton, a suture or stitch, may be placed loosely in the fistula tract to aid in healing and drainage of the abscess.
6. The operative site is irrigated and the incision is closed in layers with sutures.

4. Qualifying circumstances

CPT 46060 is performed on patients with an ischiorectal or intramural abscess that requires incision and drainage. The procedure may also involve the treatment of an anal fistula. The patient must be appropriately prepped and anesthetized for the procedure. The provider must perform the procedure submuscularly, below the muscle.

5. When to use CPT code 46060

CPT code 46060 should be used when a healthcare provider performs the incision and drainage procedure for an ischiorectal or intramural abscess, with or without the treatment of an anal fistula. The procedure must be performed submuscularly. It is important to note that CPT code 46060 should not be reported in addition to CPT code 46020.

6. Documentation requirements

To support a claim for CPT 46060, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the incision and drainage procedure
• Details of the procedure performed, including the incision and drainage of the abscess, fistulectomy or fistulotomy, and placement of seton if applicable
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46060, ensure that the procedure is performed submuscularly and includes the incision and drainage of an ischiorectal or intramural abscess, with or without the treatment of an anal fistula. Do not report CPT 46060 in addition to CPT 46020. It is important to follow the specific guidelines provided by the payer for accurate billing and reimbursement.

8. Historical information

CPT 46060 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 performs an incision and drainage procedure for an ischiorectal abscess, with fistulectomy and placement of seton.
2. A patient undergoes an incision and drainage procedure for an intramural abscess, without the treatment of an anal fistula.
3. A healthcare provider performs an incision and drainage procedure for an ischiorectal abscess, with fistulotomy and placement of seton.
4. A patient undergoes an incision and drainage procedure for an intramural abscess, with the treatment of an anal fistula.
5. A healthcare provider performs an incision and drainage procedure for an ischiorectal abscess, without the treatment of an anal fistula.
6. A patient undergoes an incision and drainage procedure for an intramural abscess, with fistulectomy and placement of seton.
7. A healthcare provider performs an incision and drainage procedure for an ischiorectal abscess, with the treatment of an anal fistula.
8. A patient undergoes an incision and drainage procedure for an intramural abscess, without the treatment of an anal fistula.
9. A healthcare provider performs an incision and drainage procedure for an ischiorectal abscess, with fistulotomy and placement of seton.
10. A patient undergoes an incision and drainage procedure for an intramural abscess, with the treatment of an anal fistula.