How To Use CPT Code 46710

CPT 46710 describes the repair of an ileoanal pouch fistula or sinus through pouch advancement using a transperineal approach. 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 46710?

CPT 46710 can be used to describe the repair of an ileoanal pouch fistula or sinus through pouch advancement. This procedure is performed by a healthcare provider to address abnormal connections or passageways between the ileoanal pouch and the perineal area or vagina. The provider removes and closes the tract, starting from the external opening, and closes the tissues to restore normal function.

2. Official Description

The official description of CPT code 46710 is: ‘Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach.’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The healthcare provider repairs the drainage tract, which is a fistula or sinus that erodes from the ileoanal pouch to the perineal area or vagina.
3. The provider removes and closes the tract, starting from the external opening.
4. The healthcare provider dissects the tract from its external origin to its origin at the ileoanal pouch.
5. The provider then closes the tissues to restore normal function.

4. Qualifying circumstances

Patients eligible to receive CPT 46710 services are those with an ileoanal pouch fistula or sinus that requires repair through pouch advancement. This procedure is commonly performed for patients who have had their large intestine surgically removed due to conditions such as ulcerative colitis, Crohn’s disease, colon cancer, or injury. The healthcare provider must assess the patient’s condition and determine the need for repair.

5. When to use CPT code 46710

CPT code 46710 should be used when a healthcare provider performs a transperineal repair of an ileoanal pouch fistula or sinus through pouch advancement. This code is appropriate for cases where the provider removes and closes the tract, starting from the external opening, and restores normal function. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 46710, the healthcare provider must document the following information:

• Patient’s diagnosis of an ileoanal pouch fistula or sinus
• Details of the repair procedure, including the transperineal approach and pouch advancement
• Date of the procedure
• Start and end time of the procedure
• Specific steps taken during the procedure, such as removal and closure of the tract
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46710, ensure that the procedure meets the criteria for this code, including the transperineal approach and pouch advancement. It is important to accurately document the details of the procedure to support the use of this code. Review the payer’s guidelines for any specific requirements or modifiers that may be necessary for proper billing.

8. Historical information

CPT 46710 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates to the code since its addition. However, it is important to stay updated with any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A healthcare provider performs a transperineal repair of an ileoanal pouch fistula for a patient who had their large intestine removed due to ulcerative colitis.
2. A patient with Crohn’s disease undergoes a transperineal repair of an ileoanal pouch sinus to restore normal function.
3. A healthcare provider performs a transperineal repair of an ileoanal pouch fistula for a patient who developed complications after colon cancer surgery.
4. A transperineal repair of an ileoanal pouch sinus is performed for a patient who experienced injury to the pouch.
5. A healthcare provider performs a transperineal repair of an ileoanal pouch fistula for a patient with a history of inflammatory bowel disease.
6. A patient with a perineal ileoanal pouch fistula undergoes a transperineal repair to address the abnormal connection.
7. A healthcare provider performs a transperineal repair of an ileoanal pouch sinus for a patient with a history of ulcerative colitis.
8. A transperineal repair of an ileoanal pouch fistula is performed for a patient who developed complications after Crohn’s disease surgery.
9. A healthcare provider performs a transperineal repair of an ileoanal pouch sinus for a patient who experienced injury to the pouch during colon cancer treatment.
10. A patient with a perineal ileoanal pouch fistula undergoes a transperineal repair to restore normal function.