How To Use CPT Code 46760

CPT 46760 describes a surgical procedure known as sphincteroplasty, which is performed to repair the anal sphincter in adult patients experiencing fecal incontinence or damage to the anal canal. This article will provide an overview of CPT code 46760, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 46760?

CPT 46760 is a code used to describe a surgical procedure called sphincteroplasty. This procedure is performed on adult patients who have experienced injury or damage to the anal canal or are suffering from fecal incontinence. During the procedure, the provider reconstructs the anal sphincter by performing a muscle transplant to repair the damaged muscle.

2. Official Description

The official description of CPT code 46760 is: ‘Sphincteroplasty, anal, for incontinence, adult; muscle transplant.’

3. Procedure

1. The patient is appropriately prepped and anesthetized, and placed in a lithotomy position.
2. A midline perianal incision is made by the provider.
3. The provider performs a sphincteroplasty using the gracilis muscle, which is taken from the inner thigh.
4. The muscle is transported to the site, preserving its blood and nerve supply, and wrapped around the anal canal.
5. If necessary, the provider may implant the graft along with a neurostimulator type electrode from a pulse generator to convert the skeletal muscle fibers of the gracilis into smooth muscle fibers, allowing the new anus muscle to maintain contraction.
6. The muscular anal ring is reattached using sutures.

4. Qualifying circumstances

CPT 46760 is performed on adult patients who have experienced injury or damage to the anal canal or are suffering from fecal incontinence. The procedure is intended to repair the anal sphincter and restore control over the muscles involved in defecation. It is important to note that this procedure is specifically for adult patients.

5. When to use CPT code 46760

CPT code 46760 should be used when a provider performs a sphincteroplasty procedure on an adult patient to repair the anal sphincter. It is important to ensure that the patient meets the qualifying circumstances for this procedure, such as experiencing fecal incontinence or damage to the anal canal.

6. Documentation requirements

To support a claim for CPT code 46760, the provider must document the following information:

• Patient’s diagnosis indicating the need for sphincteroplasty
• Details of the procedure performed, including the use of muscle transplant
• Date of the procedure
• Any additional procedures or techniques used, such as the implantation of a neurostimulator
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 46760, ensure that the procedure meets the qualifying circumstances and is performed on an adult patient. It is important to follow the specific documentation requirements and include all necessary information to support the claim. Additionally, be aware of any specific guidelines or restrictions set by the payer regarding the use of this code.

8. Historical information

CPT code 46760 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 a sphincteroplasty procedure using a muscle transplant to repair the anal sphincter.
2. An adult patient who has experienced damage to the anal canal undergoes a sphincteroplasty procedure with a muscle transplant to restore control over the anal sphincter.
3. A provider performs a sphincteroplasty procedure on an adult patient suffering from fecal incontinence, using a muscle transplant to repair the anal sphincter.
4. An individual with fecal incontinence undergoes a sphincteroplasty procedure with a muscle transplant to restore proper functioning of the anal sphincter.
5. A patient with damage to the anal canal undergoes a sphincteroplasty procedure using a muscle transplant to repair the anal sphincter and regain control over bowel movements.
6. A provider performs a sphincteroplasty procedure on an adult patient with fecal incontinence, utilizing a muscle transplant to repair the anal sphincter and improve bowel control.
7. An individual suffering from fecal incontinence undergoes a sphincteroplasty procedure with a muscle transplant to restore proper functioning of the anal sphincter and regain control over bowel movements.
8. A patient with damage to the anal canal undergoes a sphincteroplasty procedure using a muscle transplant to repair the anal sphincter and improve bowel control.
9. A provider performs a sphincteroplasty procedure on an adult patient with fecal incontinence, utilizing a muscle transplant to repair the anal sphincter and restore control over bowel movements.
10. An individual suffering from fecal incontinence undergoes a sphincteroplasty procedure with a muscle transplant to restore proper functioning of the anal sphincter and regain control over bowel movements.