How To Use CPT Code 46916

CPT 46916 describes the destruction of anal lesions using cryosurgery. 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 46916?

CPT 46916 is used to describe the destruction of anal lesions, such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicle, using cryosurgery. Cryosurgery involves using cold substances, such as liquid nitrogen or carbon dioxide, to lower the temperature of the lesion, resulting in controlled destruction.

2. Official Description

The official description of CPT code 46916 is: ‘Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery.’

3. Procedure

1. The healthcare provider identifies the anal lesions, such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicle.
2. The provider applies cold substances, such as liquid nitrogen or carbon dioxide, to the lesions.
3. The cold substances lower the temperature of the lesions to between minus 40 degrees Celsius and minus 60 degrees Celsius.
4. This controlled freezing destroys the lesions and provides better hemostasis or blood control.

4. Qualifying circumstances

CPT 46916 is used when a patient has anal lesions, such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicle, that require destruction. The procedure is performed using cryosurgery, specifically using cold substances like liquid nitrogen or carbon dioxide. The lesions must be located in the anus.

5. When to use CPT code 46916

CPT code 46916 should be used when a healthcare provider performs cryosurgery to destroy anal lesions, such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicle. It is important to note that this code is specifically for simple destruction of lesions using cryosurgery.

6. Documentation requirements

To support a claim for CPT 46916, the healthcare provider must document the following information:

• Identification of the anal lesions, such as condyloma, papilloma, molluscum contagiosum, or herpetic vesicle
• The use of cryosurgery with cold substances like liquid nitrogen or carbon dioxide
• Date of the procedure
• Details of the procedure, including the application of cold substances and the temperature achieved
• Any additional information relevant to the procedure or patient’s condition

7. Billing guidelines

When billing for CPT 46916, ensure that the procedure involves the destruction of anal lesions using cryosurgery. Use the appropriate CPT code based on the specific technique used for lesion destruction. For example, use CPT code 42900 for chemical destruction, 42910 for electrodesiccation, 46917 for laser destruction, 46922 for simple surgical excision, and 46924 for extensive lesion destruction using various techniques.

8. Historical information

CPT 46916 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 healthcare provider uses cryosurgery to destroy a condyloma on a patient’s anus.
2. A patient presents with a papilloma on their perianal skin, and the provider performs cryosurgery to remove the lesion.
3. A healthcare provider uses cryosurgery to destroy a molluscum contagiosum on a patient’s anus.
4. A patient has a herpetic vesicle on their anal area, and the provider performs cryosurgery to eliminate the lesion.
5. A healthcare provider uses cryosurgery to destroy multiple anal lesions, including condyloma, papilloma, molluscum contagiosum, and herpetic vesicle.