2025 CPT code 45113
(Active) Effective Date: N/A Revision Date: N/A Surgery - Proctectomy Digestive System Feed
Partial proctectomy with rectal mucosectomy, ileoanal anastomosis, and creation of an ileal reservoir (S or J pouch), with or without loop ileostomy.
Modifiers may be applicable depending on the circumstances of the procedure.Examples include modifiers for bilateral procedures, multiple procedures, or assistant surgeons.Consult CPT coding guidelines for proper modifier application.
Medical necessity is established by the presence of a condition requiring surgical intervention. Documentation should clearly indicate the diagnosis, treatment plan, and rationale for the specific surgical approach chosen.This should also include the patient's clinical presentation and response to less invasive treatments (if any).
The surgeon's responsibilities include preoperative assessment, surgical procedure, and postoperative care. This encompasses patient preparation, incision, resection, anastomosis, pouch creation, ileostomy (if performed), closure, and monitoring for complications.Anesthesia and other supporting medical professionals play vital roles.
In simple words: The surgeon removes part of the rectum and its inner lining.They then connect the end of the small intestine to the anus, creating a pouch to store waste.This might also involve a temporary opening in the abdomen to divert waste into a bag, which is later closed.This is done to treat conditions such as Crohn's disease or rectal cancer.
This procedure involves the partial surgical removal of the rectum (proctectomy) along with resection of the rectal mucosa (mucosectomy).An ileoanal anastomosis is then performed, connecting the ileum (the final section of the small intestine) to the anus. Simultaneously, an ileal reservoir (J-pouch or S-pouch) is created from a portion of the ileum to serve as a waste storage pouch.A loop ileostomy may or may not be included, temporarily diverting waste to an external bag. This surgery is typically indicated for conditions such as Crohn's colitis or rectal cancer.
Example 1: A 55-year-old male patient is diagnosed with rectal cancer.A partial proctectomy with rectal mucosectomy, ileoanal anastomosis, and creation of an ileal reservoir (J-pouch) is performed.A loop ileostomy is created temporarily., A 30-year-old female patient with Crohn's colitis undergoes a partial proctectomy with rectal mucosectomy, ileoanal anastomosis, and ileal reservoir creation (S-pouch). No loop ileostomy is necessary., A 60-year-old male patient with rectal cancer undergoes a partial proctectomy with rectal mucosectomy and ileoanal anastomosis, creation of an ileal reservoir (J-pouch), and a loop ileostomy. Post-operative complications arise requiring additional procedures and longer hospital stay.
Complete medical history, physical examination findings, diagnostic imaging (colonoscopy, CT scan, MRI), pathology reports (tissue analysis), operative report detailing the procedure, anesthesia record, post-operative progress notes, and any relevant complications.
** This code encompasses variations in the procedure, such as the type of ileal reservoir created (J-pouch or S-pouch) and the inclusion or exclusion of a loop ileostomy.Accurate coding requires careful review of the operative report to capture all performed elements.
- Revenue Code: Refer to your local payer's revenue code guidelines.
- RVU: RVUs vary based on geographic location and other factors. Consult your local payer's fee schedule for current values.
- Global Days : The global surgical period will depend on payer specific policies.Clarify with the specific payer.
- Payment Status: Active
- Modifier TC rule: TC modifier is not typically applicable to this code. Consult the CPT manual for clarification.
- Fee Schedule : Historical fee schedules are not consistently available for all codes.Consult your local payer or a reimbursement specialist for historical data.
- Specialties:Colorectal Surgery, General Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center