How To Use CPT Code 46606

CPT 46606 describes the procedure of anoscopy with biopsy, where a healthcare provider examines the inside of the anus using an anoscope and collects tissue samples for diagnostic purposes. 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 46606?

CPT 46606 can be used to describe the procedure of anoscopy with biopsy. During this procedure, a healthcare provider uses an anoscope, a small, rigid, tubular instrument, to examine the inside of the anus. The provider also collects tissue samples from the anal wall for further analysis and diagnosis.

2. Official Description

The official description of CPT code 46606 is: ‘Anoscopy; with biopsy, single or multiple.’ This code is specifically for the procedure of anoscopy with biopsy, where tissue samples are collected from the inside of the anus for diagnostic purposes. It is important to note that for high-resolution anoscopy (HRA) with biopsy, a different code, 46607, should be used.

3. Procedure

1. When performing anoscopy with biopsy, the healthcare provider ensures that the patient is appropriately prepped and anesthetized.
2. Using an anoscope, the provider inserts the instrument through the anal canal to access the anus and rectum.
3. The provider carefully inspects the area for any abnormalities or signs of disease.
4. If necessary, the provider uses biopsy forceps to remove one or more tissue samples from the anal wall.
5. Once sufficient samples have been obtained, the provider removes the anoscope from the patient.

4. Qualifying circumstances

CPT 46606 is used when a healthcare provider performs anoscopy with biopsy. This procedure is typically done to investigate and diagnose conditions or diseases affecting the anus and rectum. It may be necessary when there are symptoms or signs of abnormalities in this area, such as bleeding, pain, or suspicious lesions. The provider uses biopsy forceps to collect tissue samples for further analysis and diagnosis.

5. When to use CPT code 46606

CPT code 46606 should be used when a healthcare provider performs anoscopy with biopsy. This code accurately represents the procedure of examining the anus using an anoscope and collecting tissue samples for diagnostic purposes. It is important to note that if the procedure involves high-resolution anoscopy (HRA) with biopsy, CPT code 46607 should be used instead.

6. Documentation requirements

To support a claim for CPT 46606, the healthcare provider must document the following information:

• Reason for performing the anoscopy with biopsy
• Details of the procedure, including the use of an anoscope and biopsy forceps
• Location of the tissue samples collected
• Any abnormalities or findings observed during the procedure
• Any complications or adverse events that occurred
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46606, ensure that the procedure performed is anoscopy with biopsy. It is important to accurately document the details of the procedure and any relevant findings. Additionally, it is crucial to use the appropriate CPT code based on the specific procedure performed. If the procedure involves high-resolution anoscopy (HRA) with biopsy, CPT code 46607 should be used instead. It is also important to follow any specific billing guidelines provided by insurance companies or payers.

8. Historical information

CPT 46606 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 gastroenterologist performing anoscopy with biopsy to investigate rectal bleeding in a patient.
2. A colorectal surgeon using anoscopy with biopsy to diagnose a suspicious lesion found during a routine examination.
3. An oncologist performing anoscopy with biopsy to assess the extent of anal cancer in a patient.
4. A proctologist using anoscopy with biopsy to investigate chronic anal pain in a patient.
5. A dermatologist performing anoscopy with biopsy to diagnose a skin condition affecting the anus.
6. A general surgeon using anoscopy with biopsy to investigate the cause of persistent anal itching in a patient.
7. An infectious disease specialist performing anoscopy with biopsy to diagnose a sexually transmitted infection affecting the anus.
8. A pediatric gastroenterologist using anoscopy with biopsy to investigate gastrointestinal symptoms in a child.
9. An oncology nurse assisting a healthcare provider in performing anoscopy with biopsy during a cancer screening.
10. A family medicine physician using anoscopy with biopsy to investigate rectal bleeding in an elderly patient.