How To Use CPT Code 46288

CPT 46288 describes the closure of an anal fistula with a rectal advancement flap. 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 46288?

CPT 46288 is used to describe the closure of an anal fistula with a rectal advancement flap. This procedure involves excising the fistula and repairing the remaining defect by placing nearby tissue over the defect. It is typically performed in patients with high transsphincteric or suprasphincteric fistulas or for patients with complicated fistulas.

2. Official Description

The official description of CPT code 46288 is the closure of an anal fistula with a rectal advancement flap. This procedure involves excising the fistula tract and creating a flap of tissue from the surrounding area, consisting of the rectal mucosa, submucosa, and sometimes part of the internal sphincter. The flap is then advanced over the defect created by the excision of the fistula, and the incisions are closed with sutures.

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. Next, the provider identifies and excises the fistula tract.
3. A flap of tissue is created from the surrounding area, including the rectal mucosa, submucosa, and sometimes part of the internal sphincter.
4. The flap is then advanced over the defect created by the excision of the fistula.
5. The provider secures the flap with sutures and closes the incisions.

4. Qualifying circumstances

CPT 46288 is performed in patients with high transsphincteric or suprasphincteric fistulas or for patients with complicated fistulas. It involves the closure of an anal fistula using a rectal advancement flap. The procedure is typically performed by a qualified healthcare professional.

5. When to use CPT code 46288

CPT code 46288 should be used when performing the closure of an anal fistula with a rectal advancement flap. It is appropriate for patients with high transsphincteric or suprasphincteric fistulas or for patients with complicated fistulas. This code should be used to accurately report the procedure performed.

6. Documentation requirements

To support a claim for CPT 46288, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for the closure of an anal fistula
• Details of the procedure performed, including the excision of the fistula tract and the creation and advancement of the rectal advancement flap
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 46288, ensure that the procedure performed matches the description of the code. It is important to accurately report the closure of an anal fistula with a rectal advancement flap. There are no specific guidelines regarding reporting CPT 46288 with other codes.

8. Historical information

CPT 46288 was added to the Current Procedural Terminology system on January 1, 1995. There have been no updates to the code since its addition.

9. Examples

1. A patient with a high transsphincteric fistula undergoes the closure of the fistula with a rectal advancement flap.
2. A provider performs the closure of a complicated anal fistula using a rectal advancement flap in a patient.
3. A rectal advancement flap is used to close an anal fistula in a patient with a suprasphincteric fistula.
4. A healthcare professional performs the closure of an anal fistula with a rectal advancement flap in a patient with a complex fistula.
5. A qualified provider performs the closure of an anal fistula using a rectal advancement flap in a patient with a high transsphincteric fistula.
6. A patient with a complicated anal fistula undergoes the closure of the fistula with a rectal advancement flap.
7. A rectal advancement flap is used to close an anal fistula in a patient with a suprasphincteric fistula.
8. A healthcare professional performs the closure of an anal fistula with a rectal advancement flap in a patient with a complex fistula.
9. A qualified provider performs the closure of an anal fistula using a rectal advancement flap in a patient with a high transsphincteric fistula.
10. A patient with a complicated anal fistula undergoes the closure of the fistula with a rectal advancement flap.