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2025 CPT code 45560

Repair of rectocele (separate procedure)

Code 45560 is reported separately from other procedures performed at the same time, such as a hysterectomy or posterior colporrhaphy.Modifier 51 (Multiple Procedures) should be appended to 45560 if other significant procedures are performed during the same surgical session.

Modifiers may be applicable.Commonly used modifiers include 22 (Increased Procedural Services), 51 (Multiple Procedures), 59 (Distinct Procedural Service), 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician), and 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period).

Medical necessity for 45560 is established by documenting the patient’s symptoms related to the rectocele, such as vaginal bulging, difficulty with bowel movements, or discomfort.Conservative treatments should be attempted before surgery is considered, unless contraindicated.

The surgeon prepares the patient, administers anesthesia, performs the surgical repair, and provides post-operative care.

IMPORTANT:For repair of rectocele with posterior colporrhaphy, use 57250.

In simple words: This procedure fixes a bulge of the rectum into the vagina, commonly caused by childbirth. The surgeon makes an incision, puts the rectum back in place, and stitches it up to strengthen the area.

Surgical repair of a rectocele. This procedure involves the correction of a prolapse where the rectum bulges into the vagina.An incision is made in the rectovaginal septum, the herniated portion of the rectum is repositioned, and the defect is repaired with sutures, often attaching the rectum to nearby fascia for support. The area is then irrigated with antibiotics, excess vaginal tissue may be removed, and the incision is closed.

Example 1: A 45-year-old female presents with a symptomatic rectocele after multiple vaginal deliveries. She undergoes a rectocele repair (45560) to alleviate her symptoms., A 60-year-old female with a history of chronic constipation and straining experiences a rectocele. She undergoes surgical repair (45560) to address the prolapse., A 50-year-old female undergoes a hysterectomy and develops a rectocele as a post-surgical complication.The rectocele is repaired using code 45560.

Documentation should include the patient's history, physical exam findings, pre-operative diagnosis of rectocele, operative report detailing the surgical technique, and post-operative care plan.

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