How To Use CPT Code 46285

CPT 46285 describes the second stage of a surgical treatment for anal fistula. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46285?

CPT 46285 is used to describe the second stage of a surgical treatment for anal fistula. It is performed when the initial treatment is not sufficient to completely correct the fistula. During this procedure, the provider locates and excises or incises the remainder of the fistula tract, along with any seton stitches that may be in place. The wound is left open for drainage and self-healing.

2. Official Description

The official description of CPT code 46285 is: ‘Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage.’

3. Procedure

1. Several weeks after the initial fistula treatment, the provider performs the second stage of the procedure.
2. The patient is appropriately prepped and anesthetized.
3. The provider locates and excises or incises the remainder of the fistula tract.
4. If a seton stitch is in place, it is also removed during this procedure.
5. The wound is left open for drainage and self-healing.

4. Qualifying circumstances

CPT 46285 is performed when the initial treatment for an anal fistula is not sufficient to completely correct the condition. It is typically done several weeks after the initial treatment. The patient must have a severe fistula that cannot be treated in a single session. The procedure is performed by a qualified healthcare provider.

5. When to use CPT code 46285

CPT code 46285 should be used when the second stage of a surgical treatment for an anal fistula is performed. It is important to ensure that the initial treatment was not sufficient to completely correct the fistula before proceeding with the second stage. This code should not be used for the initial treatment or any subsequent stages beyond the second.

6. Documentation requirements

To support a claim for CPT 46285, the healthcare provider must document the following information:

• Details of the initial treatment and its outcome
• Date of the second stage procedure
• Description of the procedure performed, including any excisions or incisions made
• Any seton stitches removed during the procedure
• Instructions for wound care and follow-up
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46285, ensure that the procedure meets the criteria for the second stage of a surgical treatment for anal fistula. It is important to use the appropriate CPT code based on the specific stage of the treatment. CPT code 46285 should not be reported with other codes for the same procedure. It is important to follow the specific guidelines provided by the payer for accurate billing.

8. Historical information

CPT 46285 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 patient undergoes the second stage of a surgical treatment for an anal fistula, during which the provider excises the remaining fistula tract and removes a seton stitch.
2. After an initial treatment for an anal fistula, the patient requires a second stage procedure to completely correct the condition. The provider performs an incision to remove the remaining fistula tract.
3. A severe anal fistula necessitates a second stage surgical treatment. The provider excises the remaining fistula tract and leaves the wound open for drainage and self-healing.
4. Following an initial treatment for an anal fistula, the patient undergoes the second stage procedure to ensure complete correction. The provider removes a seton stitch and incises the remaining fistula tract.
5. A patient with a complex anal fistula requires the second stage of a surgical treatment. The provider excises the remaining fistula tract and leaves the wound open for drainage and self-healing.
6. After an initial treatment for an anal fistula, the patient undergoes the second stage procedure to address the remaining portion of the fistula tract. The provider performs an incision and removes any seton stitches.
7. A severe anal fistula requires a second stage surgical treatment. The provider excises the remaining fistula tract and leaves the wound open for drainage and self-healing.
8. Following an initial treatment for an anal fistula, the patient undergoes the second stage procedure to ensure complete correction. The provider removes a seton stitch and incises the remaining fistula tract.
9. A patient with a complex anal fistula requires the second stage of a surgical treatment. The provider excises the remaining fistula tract and leaves the wound open for drainage and self-healing.
10. After an initial treatment for an anal fistula, the patient undergoes the second stage procedure to address the remaining portion of the fistula tract. The provider performs an incision and removes any seton stitches.