How To Use CPT Code 46230

CPT 46230 describes the excision of multiple external papillae or tags from the anus. 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 46230?

CPT 46230 involves the removal of multiple external abnormal growths, known as external papillae or skin tags, from the anal area. These lesions are often associated with the external edge of an anal fissure or fistula. The procedure is performed by a healthcare provider to alleviate symptoms and improve the patient’s condition.

2. Official Description

The official description of CPT code 46230 is the “Excision of multiple external papillae or tags, anus.” This code specifically refers to the removal of abnormal growths from the anal area. It is important to note that this code is not applicable for the excision of a single lesion, which has its own specific code (CPT 46220).

3. Procedure

1. After appropriate patient preparation and anesthesia, the healthcare provider identifies the external papillae or skin tags in the anal area.
2. Using forceps, the provider grasps each papilla or tag and crushes it.
3. Once crushed, the provider excises the abnormal growths using surgical scissors or a surgical loop made of metal wire.
4. If necessary, the provider may apply antibiotics to the excision area to prevent infection.
5. The provider repeats these steps for all other external papillae or tags found in the anal area.

4. Qualifying circumstances

CPT 46230 is applicable when a patient presents with multiple external papillae or tags in the anal area. These growths are often associated with anal fissures or fistulas. The procedure is performed to alleviate symptoms and improve the patient’s condition. It is important to note that this code is not appropriate for the excision of a single lesion, which has its own specific code (CPT 46220).

5. When to use CPT code 46230

CPT code 46230 should be used when a healthcare provider performs the excision of multiple external papillae or tags from the anus. It is important to ensure that the patient has multiple growths and that the procedure is not limited to the removal of a single lesion. If the procedure involves the excision of a single lesion, CPT code 46220 should be used instead.

6. Documentation requirements

To support a claim for CPT 46230, the healthcare provider must document the following information:

• Patient’s diagnosis and the presence of multiple external papillae or tags
• Date of the procedure
• Details of the excision procedure, including the use of forceps, surgical scissors, or a surgical loop
• Number of external papillae or tags excised
• Any additional procedures performed, such as the application of antibiotics
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46230, ensure that the procedure involves the excision of multiple external papillae or tags from the anus. It is important to accurately document the number of growths excised. Additionally, it is crucial to use the appropriate code (CPT 46220) for the excision of a single lesion, as CPT 46230 is specifically for multiple growths. Review the documentation requirements and guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 46230 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 the excision of multiple external papillae from the anus of a patient with anal fissures.
2. During a procedure, a provider removes several skin tags from the anal area of a patient with a history of anal fistulas.
3. A patient presents with multiple external papillae in the anal region, and a healthcare provider performs their excision to alleviate discomfort and improve the patient’s condition.
4. A healthcare provider performs the excision of multiple external papillae from the anus of a patient with chronic anal irritation.
5. During a procedure, a provider removes several skin tags from the anal area of a patient with a history of recurrent anal infections.
6. A patient with external papillae in the anal region undergoes a procedure in which a healthcare provider excises the abnormal growths to relieve symptoms and improve the patient’s quality of life.
7. A healthcare provider performs the excision of multiple external papillae from the anus of a patient with anal discomfort and bleeding.
8. During a procedure, a provider removes several skin tags from the anal area of a patient with a history of anal itching and irritation.
9. A patient presents with multiple external papillae in the anal region, and a healthcare provider performs their excision to alleviate pain and improve the patient’s overall well-being.
10. A healthcare provider performs the excision of multiple external papillae from the anus of a patient with recurrent anal fissures.