How To Use CPT Code 46942

CPT 46942 describes the procedure of curettage or cautery of an anal fissure, including dilation of the anal sphincter as a subsequent treatment. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46942?

CPT 46942 is used to describe the subsequent procedure of curettage or cautery of an anal fissure, including dilation of the anal sphincter. This code represents a follow-up treatment after an initial attempt to address the anal fissure.

2. Official Description

The official description of CPT code 46942 is: ‘Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent.’

3. Procedure

1. During the subsequent procedure, the healthcare provider performs curettage or cautery of the anal fissure. Curettage involves using a small spoon-shaped instrument called a curette to scrape or scoop the fissure. Cautery, on the other hand, utilizes a cautery device, often heated by an electric current, to destroy the fissure.
2. In addition to the curettage or cautery, the provider also performs anal dilation. This involves stretching the anal sphincter using various methods to reduce the pressure in the anal canal.
3. The procedure aims to promote new tissue growth and healing in the anal fissure, ultimately alleviating the patient’s symptoms.

4. Qualifying circumstances

CPT 46942 is performed on patients with an anal fissure that requires subsequent treatment. An anal fissure refers to a break or tear in the skin of the anal canal. The procedure is typically carried out by a healthcare provider who is appropriately trained and qualified to perform the treatment. The anal dilation component of the procedure helps reduce anal canal pressure and aids in the healing process.

5. When to use CPT code 46942

CPT code 46942 should be used when a subsequent procedure of curettage or cautery of an anal fissure, including anal sphincter dilation, is performed. It is important to note that this code is specifically for subsequent treatments and should not be used for the initial procedure. For the initial procedure, refer to CPT code 46940.

6. Documentation requirements

To support a claim for CPT 46942, the healthcare provider must document the following information:

• Indication of the need for subsequent treatment of the anal fissure
• Details of the curettage or cautery procedure performed
• Description of the anal sphincter dilation technique used
• Date and duration of the procedure
• Any complications or adverse events encountered
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46942, ensure that the procedure meets the criteria for a subsequent treatment of an anal fissure. It is important to use the code accurately and not report it for the initial procedure (CPT code 46940). Additionally, consider any specific guidelines or requirements from the payer regarding documentation and reporting of this code.

8. Historical information

CPT code 46942 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 undergoes a subsequent procedure of curettage and anal sphincter dilation for the treatment of an anal fissure.
2. A healthcare provider performs cautery and anal sphincter dilation as a follow-up treatment for an anal fissure.
3. During a subsequent procedure, a curette is used to scrape the anal fissure, followed by anal sphincter dilation.
4. A patient with a persistent anal fissure undergoes a subsequent treatment involving cautery and anal sphincter dilation.
5. A healthcare provider performs curettage and anal sphincter dilation to address an anal fissure that did not heal after the initial treatment.
6. During a subsequent procedure, a healthcare provider uses cautery and anal sphincter dilation to promote healing in an anal fissure.
7. A patient with recurrent symptoms of an anal fissure undergoes a subsequent treatment involving curettage and anal sphincter dilation.
8. A healthcare provider performs cautery and anal sphincter dilation as a follow-up procedure for an anal fissure that did not respond to conservative management.
9. During a subsequent treatment, a curette is used to remove tissue from the anal fissure, followed by anal sphincter dilation.
10. A patient undergoes a subsequent procedure of cautery and anal sphincter dilation to address a persistent anal fissure.