How To Use CPT Code 46607

CPT 46607 describes the examination of the anus using high-resolution magnification and chemical agent enhancement, with biopsy. 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 46607?

CPT 46607 can be used to describe the examination of the anus using high-resolution magnification and chemical agent enhancement, with biopsy. This code is specific to high-resolution anoscopy (HRA), which involves the use of a colposcope or operating microscope to improve visibility. The provider applies a special stain, such as acetic acid, to make the tissues more visible and collects one or more samples of suspicious tissues via biopsy.

2. Official Description

The official description of CPT code 46607 is: ‘Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple.’

3. Procedure

1. The provider inserts an anoscope into the anal canal, approximately two inches deep.
2. Using high-resolution magnification (HRA) with a colposcope or operating microscope, the provider applies a chemical agent, such as acetic acid, to enhance visibility of the tissues.
3. The provider examines the tissues using the scope and performs a biopsy using biopsy forceps to collect one or more samples of suspicious tissues.
4. The collected tissue samples are sent to pathology for further analysis to diagnose the presence of any cancer or abnormal cells.

4. Qualifying circumstances

CPT 46607 is used when the provider performs high-resolution anoscopy (HRA) with biopsy. This procedure is typically performed on patients who require a closer examination of the anus and rectum, such as those with suspected cancer or abnormal cells. The use of high-resolution magnification and chemical agent enhancement improves visibility during the examination. The provider must use a colposcope or operating microscope and collect one or more tissue samples via biopsy.

5. When to use CPT code 46607

CPT code 46607 should be used when the provider performs high-resolution anoscopy (HRA) with biopsy. This code is specific to the use of a colposcope or operating microscope and the collection of one or more tissue samples via biopsy. It should not be used for similar services without high-resolution magnification and chemical agent enhancement.

6. Documentation requirements

To support a claim for CPT 46607, the provider must document the following information:

• Reason for the examination and the need for high-resolution anoscopy (HRA) with biopsy
• Use of a colposcope or operating microscope for magnification
• Application of a chemical agent, such as acetic acid, for tissue enhancement
• Date and duration of the procedure
• Number of tissue samples collected via biopsy
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 46607, ensure that the provider performs high-resolution anoscopy (HRA) with biopsy using a colposcope or operating microscope. Do not report CPT 46607 in conjunction with CPT code 69990. It is important to accurately document the procedure and use the appropriate code for the service provided.

8. Historical information

CPT 46607 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A gastroenterologist performing high-resolution anoscopy (HRA) with biopsy to examine suspicious tissues in the anus of a patient with suspected anal cancer.
2. A colorectal surgeon using a colposcope to perform high-resolution anoscopy (HRA) with biopsy on a patient with abnormal cells in the anus.
3. An oncologist performing high-resolution anoscopy (HRA) with biopsy to collect tissue samples for further analysis in a patient with suspected anal cancer.
4. A proctologist using an operating microscope to perform high-resolution anoscopy (HRA) with biopsy on a patient with abnormal cells in the anus.
5. A dermatologist performing high-resolution anoscopy (HRA) with biopsy to examine suspicious tissues in the anus of a patient with suspected skin cancer.
6. A general surgeon using a colposcope to perform high-resolution anoscopy (HRA) with biopsy on a patient with abnormal cells in the anus.
7. An oncology nurse assisting a provider in performing high-resolution anoscopy (HRA) with biopsy on a patient with suspected anal cancer.
8. A gastroenterology fellow observing a senior physician performing high-resolution anoscopy (HRA) with biopsy on a patient with abnormal cells in the anus.
9. A pathologist analyzing tissue samples collected via high-resolution anoscopy (HRA) with biopsy to determine the presence of cancer or abnormal cells.
10. A nurse documenting the details of a high-resolution anoscopy (HRA) with biopsy procedure performed by a provider on a patient with suspected anal cancer.