How To Use CPT Code 46080

CPT 46080 describes the procedure of sphincterotomy, which involves the incision of the anal sphincter to release a contracture of the anal opening. This article will provide an overview of CPT code 46080, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 46080?

CPT 46080 is a code that represents the surgical procedure known as sphincterotomy. This procedure involves the incision of the anal sphincter to release a contracture of the anal opening. It is typically performed to alleviate symptoms caused by a narrowing or tightening of the anal canal, allowing for improved fecal retention control.

2. Official Description

The official description of CPT code 46080 is: ‘Sphincterotomy, anal, division of sphincter (separate procedure).’ This code specifically refers to the surgical division of the anal sphincter to relieve a contracture.

3. Procedure

1. During the procedure, the provider prepares the patient and administers anesthesia.
2. The provider then dilates the anus to expose the anal canal.
3. Next, the provider locates the anal sphincter and carefully incises between the muscle layers using a scalpel.
4. If any bleeding occurs, the provider takes necessary measures to control it.
5. Finally, the provider may irrigate the area with antibiotics to prevent infection.

4. Qualifying circumstances

CPT 46080 is typically performed on patients who have a contracture of the anal opening, resulting in symptoms that require surgical intervention. The procedure is performed by a qualified healthcare provider who has the necessary expertise to perform sphincterotomy. It is important to note that CPT 46080 should not be reported if any other major procedure is performed in the same location and session.

5. When to use CPT code 46080

CPT code 46080 should be used when a provider performs a sphincterotomy as a separate procedure to address a contracture of the anal opening. It is important to ensure that no other major procedures are performed in the same location and session to accurately report this code.

6. Documentation requirements

To support a claim for CPT code 46080, the provider must document the following information:

• Patient’s diagnosis indicating the need for sphincterotomy
• Description of the procedure performed, including the incision of the anal sphincter
• Date of the procedure
• Details of any complications or additional measures taken during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 46080, it is important to ensure that the procedure is performed as a separate procedure and not in conjunction with any other major procedures in the same location and session. It is also essential to follow any specific guidelines provided by the payer regarding the use of this code. Additionally, it is crucial to accurately document and code any complications or additional measures taken during the procedure.

8. Historical information

CPT code 46080 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 patient undergoes sphincterotomy to relieve a contracture of the anal opening caused by a previous injury.
2. A provider performs sphincterotomy on a patient with a chronic anal fissure that has not responded to conservative treatment.
3. A patient with an anal abscess undergoes sphincterotomy to drain the abscess and alleviate symptoms.
4. A provider performs sphincterotomy on a patient with anal stenosis to improve fecal retention control.
5. A patient with a history of Crohn’s disease undergoes sphincterotomy to address a contracture of the anal opening.
6. A provider performs sphincterotomy on a patient with anal cancer to relieve symptoms and improve quality of life.
7. A patient with a congenital anal malformation undergoes sphincterotomy as part of their treatment plan.
8. A provider performs sphincterotomy on a patient with an anal fistula to address the underlying condition.
9. A patient with a history of radiation therapy undergoes sphincterotomy to alleviate symptoms of radiation-induced anal contracture.
10. A provider performs sphincterotomy on a patient with fecal incontinence to improve control over bowel movements.