How To Use CPT Code 46615

CPT 46615 describes the procedure of anoscopy with ablation of tumor(s), polyp(s), or other lesion(s) that cannot be removed by hot biopsy forceps, bipolar cautery, or snare technique. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46615?

CPT 46615 is used to describe a specific procedure called anoscopy with ablation. This procedure is performed by a healthcare provider using an anoscope, a small, rigid, tubular instrument. The provider removes tumors, polyps, or other lesions that cannot be removed by hot biopsy forceps, bipolar cautery, or snare technique. Instead, the provider uses methods such as argon plasma coagulation (APC), heater probe, or other devices to ablate the abnormalities.

2. Official Description

The official description of CPT code 46615 is: ‘Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate anesthesia and prepping the area.
2. The provider inserts an anoscope into the anal canal to visualize the area.
3. Using the anoscope, the provider inspects the area for any tumors, polyps, or lesions that cannot be removed by hot biopsy forceps, bipolar cautery, or snare technique.
4. If any abnormalities are found, the provider uses methods such as argon plasma coagulation (APC), heater probe, or other devices to ablate the tumors, polyps, or lesions.
5. The provider carefully removes the anoscope and ensures the patient’s comfort and safety.

4. Qualifying circumstances

CPT 46615 is used when the tumors, polyps, or lesions cannot be removed by hot biopsy forceps, bipolar cautery, or snare technique. The procedure is performed by a healthcare provider who is qualified to perform anoscopy and ablation. The patient must have tumors, polyps, or lesions that require ablation, and other methods of removal are not suitable for their condition.

5. When to use CPT code 46615

CPT code 46615 should be used when a healthcare provider performs anoscopy with ablation of tumors, polyps, or lesions that cannot be removed by hot biopsy forceps, bipolar cautery, or snare technique. It is important to ensure that other methods of removal are not suitable for the patient’s condition before using this code.

6. Documentation requirements

To support a claim for CPT 46615, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for anoscopy with ablation
• Specific details of the procedure performed, including the use of argon plasma coagulation (APC), heater probe, or other devices
• Date and time of the procedure
• Any complications or adverse events that occurred during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46615, ensure that the procedure meets the specific criteria outlined in the code description. It is important to document the medical necessity of the procedure and provide appropriate supporting documentation. CPT code 46615 should not be reported with other codes for removal of tumors, polyps, or lesions using hot biopsy forceps, bipolar cautery, or snare technique.

8. Historical information

CPT 46615 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs anoscopy with ablation to remove a tumor in the anal canal that cannot be removed by hot biopsy forceps.
2. An individual undergoes anoscopy with ablation to treat a polyp in the rectum that cannot be removed by bipolar cautery.
3. A patient with a lesion in the anus undergoes anoscopy with ablation using argon plasma coagulation (APC) to remove the abnormal tissue.
4. A healthcare provider performs anoscopy with ablation to treat multiple tumors in the anal canal that cannot be removed by snare technique.
5. An individual undergoes anoscopy with ablation to remove a polyp in the rectum that cannot be removed by hot biopsy forceps or bipolar cautery.
6. A patient with a lesion in the anus undergoes anoscopy with ablation using a heater probe to remove the abnormal tissue.
7. A healthcare provider performs anoscopy with ablation to remove a tumor in the anal canal that cannot be removed by hot biopsy forceps or snare technique.
8. An individual undergoes anoscopy with ablation to treat a polyp in the rectum that cannot be removed by bipolar cautery or snare technique.
9. A patient with a lesion in the anus undergoes anoscopy with ablation using argon plasma coagulation (APC) and a heater probe to remove the abnormal tissue.
10. A healthcare provider performs anoscopy with ablation to remove multiple tumors in the anal canal that cannot be removed by hot biopsy forceps or bipolar cautery.