How To Use CPT Code 46746

CPT 46746 describes the repair of a cloacal anomaly using an anorectovaginoplasty and urethroplasty technique, with a combined abdominal and sacroperineal 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 46746?

CPT 46746 can be used to describe the surgical repair of a cloacal anomaly in females. The procedure involves repairing an anorectal and vaginal defect or malformation, as well as any injury to the urethral wall. The repair is performed using a combined abdominal and sacroperineal approach.

2. Official Description

The official description of CPT code 46746 is: ‘Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach.’

3. Procedure

1. The provider begins by making a small incision in the perineum if the confluence of organs is relatively close to the surface.
2. Using a combined abdominal and sacroperineal approach, the provider separates the bladder, urethra, and vagina from each other.
3. If the bladder is swollen, the provider decompresses it.
4. The provider then places the opening of the vagina and the urethra in their appropriate positions.
5. A new rectum is formed from muscle posterior to the rectum.
6. The provider closes the incisions with sutures.

4. Qualifying circumstances

CPT 46746 is used for patients with a cloacal anomaly, which is a complex anorectal and genitourinary malformation where the rectum, vagina, and urinary tract meet and fuse, creating a single common channel. The procedure is performed on females. The combined abdominal and sacroperineal approach is used to repair the anomaly and any injury to the urethral wall.

5. When to use CPT code 46746

CPT code 46746 should be used when a provider performs a repair of a cloacal anomaly in females using an anorectovaginoplasty and urethroplasty technique, with a combined abdominal and sacroperineal approach. This code should not be used for other types of repairs or approaches.

6. Documentation requirements

To support a claim for CPT 46746, the provider must document the following information:

• Patient’s diagnosis of a cloacal anomaly
• Description of the repair technique used (anorectovaginoplasty and urethroplasty)
• Details of the combined abdominal and sacroperineal approach
• Date of the procedure
• Any additional relevant information or complications
• Provider’s signature

7. Billing guidelines

When billing for CPT 46746, ensure that the procedure meets the criteria for a cloacal anomaly repair using an anorectovaginoplasty and urethroplasty technique, with a combined abdominal and sacroperineal approach. There are no specific guidelines regarding reporting this code with other codes. However, it is important to accurately document and code all services provided during the procedure.

8. Historical information

CPT 46746 was added to the Current Procedural Terminology system on January 1, 1994. The code description was revised on January 1, 2010. It is important to stay updated with any changes or revisions to the code.

9. Examples

1. A provider performs a combined abdominal and sacroperineal repair of a cloacal anomaly in a female patient.
2. Using an anorectovaginoplasty and urethroplasty technique, the provider repairs the anorectal and vaginal defect, as well as any injury to the urethral wall.
3. The procedure is documented and coded as CPT 46746.
4. Another provider performs a repair of a cloacal anomaly using a different approach, such as the sacroperineal approach (CPT 46744) or the abdominal approach (CPT 46747).
5. Each case is coded according to the specific procedure performed.