tci Medicare Compliance & Reimbursement - 2011 Issue 5

Reader Questions: Consider 45990 for Rectal Exam With Anesthesia

Question: I can't seem to find a proper CPT code for this: The surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off but the large vessel underneath was continuing to bleed (all done under anesthesia). He then sutured the bleeding site. Any suggestions?Answer: The procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). Do not report 45990 in conjunction with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic...

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