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The CPT® Code 45005 refers to the procedure of incision and drainage of a submucosal abscess located in the rectum. A submucosal abscess is a collection of pus that forms beneath the mucosal layer of the rectal wall, often resulting from infection or inflammation. This procedure is essential for alleviating pain, preventing further complications, and promoting healing by allowing the pus to escape. During the procedure, a proctoscope or sigmoidoscope may be utilized to accurately locate the abscess. The surgeon makes an incision, typically in a radial or cross-shaped (cruciate) manner, over the area where the abscess is most prominent, ideally as close to the anal verge as possible. This incision allows for the excision of the edges to expose the abscess cavity fully, facilitating effective drainage. Depending on the clinical situation, the incision may be left open to allow for continuous drainage, packed with iodophor gauze for a specified duration, or a drain may be placed to ensure proper outflow of any remaining fluid. This procedure is critical in managing rectal abscesses and preventing the development of more severe conditions, such as sepsis or the formation of fistulas.
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The procedure described by CPT® Code 45005 is indicated for the management of a submucosal abscess of the rectum. The following conditions may warrant this intervention:
The procedure for incision and drainage of a submucosal abscess of the rectum involves several critical steps to ensure effective treatment. First, the patient is positioned appropriately, and anesthesia is administered to minimize discomfort during the procedure. A proctoscope or sigmoidoscope is then introduced to visualize the rectal cavity and accurately locate the abscess. Once the abscess is identified, the surgeon makes a radial or cross-shaped (cruciate) incision over the area of fluctuance, which is the point where the abscess is most prominent. This incision is made as close to the anal verge as possible to facilitate drainage.
After the incision is made, the edges of the incision are excised to expose the abscess cavity fully. This step is crucial as it allows for wide drainage of the pus contained within the abscess. The surgeon may then probe the abscess cavity with a gloved finger to break up any loculations, ensuring that the entire cavity is adequately drained. The abscess cavity is inspected for any potential fistulous tracts that may need to be addressed. Following the drainage, the incision may be left open to allow for continuous drainage, packed with iodophor gauze for a period of 24 hours, or a drain may be placed to facilitate further outflow of any remaining fluid.
After the procedure, patients are typically monitored for any signs of complications, such as excessive bleeding or infection. The incision site may be left open to promote drainage, and patients are advised on proper care of the area to prevent infection. If iodophor gauze is used, it is usually removed after 24 hours, and the site should be kept clean and dry. Follow-up appointments may be necessary to assess healing and ensure that the abscess has resolved completely. Patients should be instructed to report any unusual symptoms, such as increased pain, fever, or changes in bowel habits, as these may indicate complications that require further medical attention.
| Short Descr | DRAINAGE OF RECTAL ABSCESS | Medium Descr | I&D SUBMUCOSAL ABSCESS RECTUM | Long Descr | Incision and drainage of submucosal abscess, rectum | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 96 - Other OR lower GI therapeutic procedures |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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