How To Use CPT Code 46750

CPT 46750 describes the surgical procedure known as anal sphincteroplasty, which is performed to treat fecal incontinence or prolapse in adult patients. This article will provide an overview of CPT code 46750, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46750?

CPT 46750 is used to describe the surgical procedure called anal sphincteroplasty. This procedure involves the reconstruction of the anal sphincter, which is the muscle responsible for controlling the closing of the anus. It is performed in adult patients who experience fecal incontinence or prolapse, which is the dropping or sliding of the anal sphincter from its normal position. The purpose of the surgery is to restore the function and anatomy of the anal sphincter, thereby addressing the patient’s condition.

2. Official Description

The official description of CPT code 46750 is: ‘Sphincteroplasty, anal, for incontinence or prolapse; adult.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider places the patient in a lithotomy position, which involves positioning the patient on their back with their knees bent and spread apart using stirrups.
3. An incision is made at the midline of the perineal area.
4. The provider identifies the external and internal sphincter muscles.
5. The two ends of the muscle are excised and overlapped onto one another.
6. The provider sutures the external and internal sphincter muscles together to build a separate perineal body.
7. An end-to-end sphincter suture is performed to complete the procedure.

4. Qualifying circumstances

CPT 46750 is performed in adult patients who have fecal incontinence or prolapse. Fecal incontinence refers to the loss of control of the rectal muscles or nerves, resulting in involuntary leakage and excretion. Prolapse, on the other hand, is the dropping, falling, sinking, or sliding of an organ from its normal position. In this case, it refers to the anal sphincter. The procedure is intended to reconstruct the anal sphincter and restore its normal function. It is important to note that CPT 46750 is applicable only for adult patients.

5. When to use CPT code 46750

CPT code 46750 should be used when a provider performs anal sphincteroplasty in adult patients with fecal incontinence or prolapse. It is important to ensure that the patient meets the qualifying circumstances for this procedure. If the patient does not have fecal incontinence or prolapse, or if the patient is not an adult, CPT code 46750 should not be used.

6. Documentation requirements

To support a claim for CPT 46750, the provider must document the following information:

• Patient’s diagnosis of fecal incontinence or prolapse
• Details of the procedure, including the incision, excision, overlapping of muscle ends, and suturing
• Date of the procedure
• Any additional relevant information, such as the patient’s response to the surgery
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 46750, it is important to ensure that the procedure is performed in adult patients with fecal incontinence or prolapse. It should not be reported with other codes unless necessary. Providers should follow the specific guidelines provided by the payer and ensure accurate documentation to support the claim.

8. Historical information

CPT code 46750 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 patient with fecal incontinence undergoes anal sphincteroplasty to reconstruct the anal sphincter and restore control over bowel movements.
2. An adult patient with anal sphincter prolapse undergoes anal sphincteroplasty to correct the prolapse and restore the normal position of the sphincter.
3. A provider performs anal sphincteroplasty on a patient with both fecal incontinence and prolapse to address both conditions simultaneously.
4. An adult patient with fecal incontinence resulting from a previous injury undergoes anal sphincteroplasty to restore control over bowel movements.
5. A patient with anal sphincter prolapse due to weakened muscles undergoes anal sphincteroplasty to strengthen and reconstruct the sphincter.
6. A provider performs anal sphincteroplasty on an adult patient with fecal incontinence caused by a congenital condition to improve their quality of life.
7. An adult patient with fecal incontinence resulting from a previous surgery undergoes anal sphincteroplasty to correct the issue and regain control over bowel movements.
8. A patient with anal sphincter prolapse due to aging undergoes anal sphincteroplasty to restore the normal position and function of the sphincter.
9. An adult patient with fecal incontinence caused by a medical condition undergoes anal sphincteroplasty to address the issue and improve their quality of life.
10. A provider performs anal sphincteroplasty on an adult patient with anal sphincter prolapse caused by trauma to restore the normal anatomy and function of the sphincter.