How To Use CPT Code 46200

CPT 46200 describes the procedure known as fissurectomy, which involves the removal of an anal fissure and may include incising the anal sphincter. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46200?

CPT 46200 is a code used to describe the surgical procedure known as fissurectomy. This procedure involves the incision and removal of an anal fissure, which is a crack or tear in the skin of the anal canal. In some cases, the provider may also need to incise the anal sphincter muscle as part of the treatment. The purpose of this procedure is to alleviate symptoms and promote healing of the anal fissure.

2. Official Description

The official description of CPT code 46200 is: ‘Fissurectomy, including sphincterotomy, when performed.’

3. Procedure

1. When performing a fissurectomy, the provider begins by appropriately prepping and anesthetizing the patient.
2. Next, the provider locates the anal sphincter and may incise it with a scalpel to release any contracture or gain access to the fissure.
3. The provider then incises around the fissure and removes it along with the surrounding tissues.
4. If necessary, the provider may also need to incise the internal sphincter muscle as part of the procedure.
5. After completing the fissurectomy, the provider irrigates the site with antibiotics and leaves it open for healing.

4. Qualifying circumstances

CPT 46200 is performed on patients who have an anal fissure that requires surgical intervention. The procedure may also include sphincterotomy, which is the incision or stretching of the anal sphincter muscle. The decision to perform a fissurectomy is based on the patient’s symptoms and the severity of the fissure. The provider must assess the patient and determine the need for this surgical procedure.

5. When to use CPT code 46200

CPT code 46200 should be used when a provider performs a fissurectomy, including sphincterotomy, for the treatment of an anal fissure. It is important to note that this code should only be used when the procedure is performed and not for evaluation or management of the condition. If the provider performs additional procedures or services during the same encounter, separate codes should be used to report those services.

6. Documentation requirements

To support a claim for CPT code 46200, the provider must document the following information:

• Patient’s diagnosis of an anal fissure
• Details of the procedure performed, including the incision and removal of the fissure and any sphincterotomy
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 46200, ensure that the procedure performed includes both fissurectomy and sphincterotomy. It is important to use the appropriate code based on the specific services provided. If additional procedures or services are performed during the same encounter, separate codes should be used to report those services. It is also important to follow any specific billing guidelines provided by the payer to ensure accurate reimbursement.

8. Historical information

CPT code 46200 was added to the Current Procedural Terminology system on January 1, 1990. There was a code change on January 1, 2010, which revised the description of the procedure to include or exclude sphincterotomy.

9. Examples

1. A provider performs a fissurectomy, including sphincterotomy, to treat an anal fissure in a patient.
2. A patient with a chronic anal fissure undergoes a fissurectomy with sphincterotomy to alleviate symptoms and promote healing.
3. A provider performs a fissurectomy and incises the anal sphincter to release a contracture and remove the anal fissure.
4. A patient with a severe anal fissure undergoes a fissurectomy with sphincterotomy and irrigation of the site for healing.
5. A provider performs a fissurectomy and incises the internal sphincter muscle to treat an anal fissure.
6. A patient with recurrent anal fissures undergoes a fissurectomy with sphincterotomy to address the underlying issue.
7. A provider performs a fissurectomy and leaves the site open for healing in a patient with an anal fissure.
8. A patient with a painful anal fissure undergoes a fissurectomy with sphincterotomy to relieve symptoms.
9. A provider performs a fissurectomy and irrigates the site with antibiotics to prevent infection.
10. A patient with a chronic anal fissure undergoes a fissurectomy with sphincterotomy to improve their quality of life.