How To Use CPT Code 46751

CPT 46751 describes a surgical procedure known as sphincteroplasty, which is performed on children to repair a defect or tear in the anal sphincter. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46751?

CPT 46751 is a code used to describe a surgical procedure called sphincteroplasty, which is performed on children. This procedure involves the reconstruction of the anal sphincter to repair a defect or tear in the muscular covering of the anal canal. It is typically done to address issues of incontinence or prolapse in children.

2. Official Description

The official description of CPT code 46751 is: ‘Sphincteroplasty, anal, for incontinence or prolapse; child.’

3. Procedure

1. The surgeon begins by making an incision in the midline of the perineal area, which is the region between the anus and the scrotum in males or between the anus and the vulva in females.
2. Next, the surgeon identifies the anal muscles responsible for controlling fecal movement.
3. The two ends of the muscle are excised, and the surgeon overlaps them onto one another.
4. The external and internal sphincter muscles, which control the closing of the anus, are isolated and sutured together.
5. This process helps to build a separate perineal body and restore the circle of muscle.
6. The procedure aims to reconstruct the anal sphincter and approximate its normal anatomy, thereby addressing issues of fecal incontinence or prolapse.

4. Qualifying circumstances

CPT 46751 is applicable when the procedure is performed on a child who requires sphincteroplasty to treat incontinence or prolapse. The surgery is typically performed by a qualified surgeon who specializes in pediatric procedures.

5. When to use CPT code 46751

CPT code 46751 should be used when a surgeon performs sphincteroplasty on a child to address issues of incontinence or prolapse. It is important to ensure that the procedure is performed specifically on a child and not an adult, as there is a separate code for adult patients (CPT 46750).

6. Documentation requirements

To support a claim for CPT 46751, the surgeon must document the following information:

• Patient’s age and indication for sphincteroplasty
• Description of the defect or tear in the anal sphincter
• Details of the surgical procedure performed, including the incision site and technique used
• Any additional procedures or repairs performed during the same surgical session
• Post-operative care instructions and follow-up plans
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 46751, it is important to ensure that the procedure is performed on a child and not an adult. This code should not be reported with CPT code 46750, which is specifically for adult patients. It is essential to follow the specific guidelines provided by the payer and accurately document the procedure to support the claim.

8. Historical information

CPT code 46751 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was also added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A pediatric surgeon performs sphincteroplasty on a 6-year-old child with fecal incontinence.
2. A 4-year-old child undergoes sphincteroplasty to repair a tear in the anal sphincter caused by prolapse.
3. A 7-year-old patient with incontinence undergoes sphincteroplasty to reconstruct the anal sphincter.
4. A 9-year-old child with prolapse undergoes sphincteroplasty to restore the normal anatomy of the anal sphincter.
5. A pediatric surgeon performs sphincteroplasty on a 5-year-old patient with both incontinence and prolapse.
6. A 3-year-old child undergoes sphincteroplasty to repair a defect in the anal sphincter and address issues of incontinence.
7. A 8-year-old patient with prolapse undergoes sphincteroplasty to improve anal muscle function and prevent further complications.
8. A pediatric surgeon performs sphincteroplasty on a 10-year-old child with fecal incontinence caused by a tear in the anal sphincter.
9. A 2-year-old patient undergoes sphincteroplasty to repair a defect in the anal sphincter and restore normal bowel control.
10. A 6-year-old child with prolapse undergoes sphincteroplasty to strengthen the anal sphincter and prevent further complications.