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2025 CPT code 46607

Anoscopy with high-resolution magnification (HRA) and chemical agent enhancement, with biopsy.

Follow all relevant CPT guidelines for anoscopy and biopsy procedures.Proper use of modifiers, if necessary, should be documented and supported by the clinical context.

Modifiers may apply depending on the circumstances. For example, modifier 51 (multiple procedures) might apply if other procedures are performed during the same session. Consult the official CPT manual and payer guidelines for applicable modifiers.

Medical necessity for 46607 is established when clinical findings (e.g., bleeding, pain, visible lesions) suggest the presence of abnormal anal tissue requiring histopathological examination to confirm or rule out conditions like cancer, dysplasia, or infections.

The physician inserts a scope into the anal canal, applies a chemical agent, examines the tissue using high-resolution magnification, and performs a biopsy to obtain tissue samples for pathology analysis.

IMPORTANT:Do not report 46607 in conjunction with 69990.Code 46606 (Anoscopy; with biopsy, single or multiple) is used for similar services without HRA. Code 46601 (Anoscopy; diagnostic, with high resolution magnification, HRA, and chemical agent enhancement, including collection of specimen or specimens by brushing or washing, when performed) is used if specimen collection is done by brushing or washing.

In simple words: The doctor uses a special scope with magnification and a special solution to get a very clear look inside the anus. They then take a small tissue sample to check for any problems under a microscope.

This procedure involves a diagnostic anoscopy using high-resolution magnification (HRA), such as a colposcope or operating microscope, and chemical agent enhancement to improve visualization of the anal canal. A biopsy, either single or multiple, is performed to collect tissue samples for pathological examination.The procedure aims to diagnose the presence of cancerous or other abnormal cells.

Example 1: A patient presents with rectal bleeding and suspicious lesions during a routine checkup. The physician performs a 46607 procedure to obtain a biopsy for further evaluation. , A patient with a history of anal warts undergoes a 46607 procedure to assess the extent of the disease and rule out malignancy. Biopsies reveal early-stage cancer, necessitating further treatment., A patient with unexplained anal discomfort undergoes a 46607 procedure. Biopsy results are negative for malignancy. The physician considers other causes for the discomfort such as hemorrhoids, anal fissures, or other conditions.

Detailed documentation should include the indication for the procedure (e.g., symptoms, prior imaging studies), description of the findings during the HRA, the number and location of biopsies taken, and the results of the pathological analysis.Proper pre-operative and post-operative notes should also be maintained.

** The use of a colposcope or operating microscope is optional for this code.The choice of instrument depends on the specific clinical situation and the physician’s preference. The chemical agent used for enhancement should be documented.

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