General Surgery Coding Alert

Distinguishing Rectal I&D from Anal I&D Codes

Published on Fri Feb 01, 2002 Updated on Fri Feb 01, 2002

Reviewed on May 15, 2015

Coding the treatment of rectal and anal abscesses presents certain challenges because your surgeon may not use the precise language included in the CPT^® code definitions. Simply determining whether a procedure should be considered a rectal or anal I&D can be difficult, for example, because the I&D codes in the anus section refer to the rectum and vice versa. Terms such as perirectal and perianal describe the general area around the rectum and anus and as such can be interpreted in many different ways.

Surgeons and coders can work together to alleviate any confusion in coding these procedures. Surgeons should dictate at least the top portion of their operative reports in language that matches the language of the appropriate code descriptors. Coders should work with surgeons to pinpoint the location of the abscess and the procedure that was performed. This can also be difficult says M. Trayser Dunaway MD a general surgeon in private practice in Camden S.C.: "The problem is that identification of the location of an anal or rectal abscess can be extremely subjective. There is a lot of variation in the anatomy itself and in how surgeons describe the anatomy. As a result five surgeons can dictate five entirely different descriptions about the same procedure."

Rectal I&D and anal I&D codes include:

45000 transrectal drainage of pelvic abscess
45005 incision and drainage of submucosal abscess rectum
45020 incision and drainage of deep supralevator pelvirectal or retrorectal abscess
46040 incision and drainage of ischiorectal and/or perirectal abscess (separate procedure)
46045 incision and drainage of intramural intramuscular or submucosal abscess transanal under anesthesia
46050 incision and drainage perianal abscess superficial
46060 incision and drainage of ischiorectal or intramural abscess with fistulectomy or fistulotomy submuscular with or without placement of seton.

Rectal I&D (45000-45020)

One major difference between the rectal I&D codes and the anal I&D codes, Dunaway says, is that rectal codes are used if drainage is transrectal or performed through the rectum and anal codes are used if drainage is through the skin adjacent to the anus. "Speaking as a surgeon who's been draining these things for years I had never considered why perirectal abscess codes would be found in the anal section. I think that most surgeons would also be puzzled unless the codes were looked at from the perspective of the surgical approach," he says.

Use 45000 if the rectum wall is opened so that a pelvic abscess can be drained. Code 45005 is appropriate if an abscess between the mucosa and the muscularis in the rectum is drained through an opening in the mucosal wall of the rectum. Use 45020 when draining abscesses that have formed in deep cavities such as the supralevator the pelvirectal cavity or the retrorectal space.

Anal I&D (46040-46060)

I&D of a superficial perianal abscess (46050) typically performed in the surgeon's office is the simplest of anal I&D procedures. Use 46040 if the abscess is perirectal and/or ischiorectal but do not use 46040 if another procedure is performed in the same anatomical region. Code 46045 is appropriate if deeper I&D is required because the abscess is submucosal or intramuscular.

Use 46060 if a fistula has formed and needs to be either cut (fistulotomy) or removed (fistulectomy) regardless of whether a seton is implanted. A seton inserted during a different procedure may be reported with 46020 (placement of seton) a code introduced in CPT® 2002. Code 46020 should not be reported with 46060 for the same operative session.

Subsequent Debridements

One or more debridements may be required after I&D of an abscess, particularly for large cavities requiring anesthesia to repack, assure proper continued drainage, and remove nonviable tissue. Although these debridements are performed during the global period of the earlier I&D, they may be reported separately with modifier -58 (staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period).

Note: Some carriers may prefer modifier -79 (unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period).

Subsequent debridements are reported with one of the following codes depending on the depth of debridement: 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less ), +11045 (…each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure ), 11043 (Debridement, muscle and/or fascia includes epidermis, dermis, and subcutaneous tissue, if performed]; first 20 sq cm or less),

+11046 (…each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure] ), 97597 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less), or 97598 (…each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure])

Debridements are exempt from the global period because the infection being debrided is not a complication of the original I&D which was performed to treat the same infection.

Physician Documentation

The anatomical differences among the codes can be subject to much interpretation, so surgeons must become more familiar with CPT^® terminology and use it to describe accurately what was performed says Barbara Cobuzzi MBA CPC CPC-H a coding and reimbursement specialist and president of Cash Flow Solutions a medical billing firm in Lakewood N.J. "Many surgeons dictate their operative reports using clinical terminology which does not always correspond to CPT® style " Cobuzzi says.

She says that if the coder reviewing the claim form or selecting the code has not talked with the surgeon and is unfamiliar with the procedure and/or the appropriate medical terminology a coding mix-up may result. "Surgeons need to use CPT^® terminology more in their operative reports," Cobuzzi says. "If not in the procedure notes themselves, then certainly at the top of the op note." If that is not done and the operative report does not paint a clear picture for the coder the surgeon should be asked for clarification she says.