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rectal exam under anesthesia

  1. Default rectal exam under anesthesia
    Medical Coding Books
    We have a physician who performed a rectal exam under general anesthesia due to the patient being Down's syndrome and unable to have exam in the office.

    Digital rectal exam was done, but no scopes.

    45990 shows anorectal exam under anesthesia- but included anoscope/ rigid proctosigmoidoscope.

    neither of these were done.

    Is is more appropriate to use unlisted rectal Code/ or to code E/M visit?

    (exam found to show anal fissures and compacted hard stool)

  2. #2
    Milwaukee WI
    Default Disimpaction?
    Patient was under general anesthesia so I would not use E/M code.

    Was the impacted feces removed? Could you code 45915?

    If not, I'd be inclined to bill 45990 with -52 modifier for reduced service.

    F Tessa Bartels, CPC, CPC-E/M

  3. #3
    Pittsburgh Central Pennsylvania
    I would go w/ the 45990-52 for this one....

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