How To Use CPT Code 46753

CPT 46753 describes the Thiersch operation, a surgical procedure used to treat rectal incontinence and/or prolapse. 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 46753?

CPT 46753 can be used to describe the Thiersch operation, a surgical procedure performed to address rectal incontinence and/or prolapse. During this procedure, the provider places a skin graft, suture, or steel wire around the anal canal to create a barrier for the passage of rectal contents, narrowing the anal opening and preventing the protrusion of the rectum.

2. Official Description

The official description of CPT code 46753 is: ‘Graft (Thiersch operation) for rectal incontinence and/or prolapse.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a small incision behind the anus and on the opposite side in the front midline.
3. Sutures, a skin graft, or steel wire with an aneurysm needle are inserted through the posterior incision and brought forward and through the anterior incision, encircling the anal canal.
4. The sutures, graft, or steel wire are tied subcutaneously in the body fat of the ischiorectal fossa, creating a barrier for the passage of rectal contents.
5. The provider closes the incisions at the end of the procedure.

4. Qualifying circumstances

CPT 46753 is used for patients with rectal incontinence and/or prolapse. Rectal incontinence refers to the lack of control over the muscles involved in defecation, leading to involuntary loss of bowel contents. Rectal prolapse occurs when a part of the rectum projects from its normal position. The procedure is performed by a qualified healthcare provider who is trained in performing the Thiersch operation.

5. When to use CPT code 46753

CPT code 46753 should be used when the Thiersch operation is performed to address rectal incontinence and/or prolapse. It is important to ensure that the procedure performed aligns with the official description of the code. If the procedure performed does not meet the criteria outlined in the official description, a different code should be used.

6. Documentation requirements

To support a claim for CPT 46753, the healthcare provider must document the following information:

• Patient’s diagnosis of rectal incontinence and/or prolapse
• Description of the Thiersch operation performed
• Date of the procedure
• Details of the incisions made and the materials used (sutures, graft, or steel wire)
• Any additional relevant information or complications encountered during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46753, ensure that the procedure performed aligns with the official description of the code. It is important to accurately document the details of the procedure and any additional relevant information. CPT code 46753 should not be reported with other codes unless additional procedures were performed that are separately reportable. It is crucial to follow the specific billing guidelines provided by the payer to ensure accurate reimbursement.

8. Historical information

CPT 46753 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes the Thiersch operation to address rectal incontinence.
2. A provider performs the Thiersch operation to treat rectal prolapse in a patient.
3. A qualified healthcare professional performs the Thiersch operation on a patient with both rectal incontinence and prolapse.
4. A patient with rectal incontinence undergoes the Thiersch operation using a skin graft.
5. A provider performs the Thiersch operation on a patient with rectal prolapse using sutures.
6. A qualified healthcare professional performs the Thiersch operation on a patient with rectal incontinence and prolapse using steel wire.
7. A patient undergoes the Thiersch operation to address rectal incontinence and prolapse simultaneously.
8. A provider performs the Thiersch operation on a patient with rectal prolapse, using a combination of sutures and a skin graft.
9. A qualified healthcare professional performs the Thiersch operation on a patient with rectal incontinence, using steel wire and a skin graft.
10. A patient undergoes the Thiersch operation to address both rectal incontinence and prolapse, using sutures and a skin graft.