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The procedure described by CPT® Code 45113 refers to a partial proctectomy combined with rectal mucosectomy, ileoanal anastomosis, and the creation of an ileal reservoir, which can be configured in either an S or J shape. This surgical intervention is typically indicated for patients with conditions affecting the rectum, such as inflammatory bowel disease, rectal cancer, or other significant rectal pathologies that necessitate the removal of a portion of the rectum while preserving anal function. The procedure involves a midline abdominal incision to access the abdominal cavity, allowing for the exploration and identification of the proximal transection site, which may include the sigmoid colon. The mobilization of the sigmoid colon and rectum is crucial for the subsequent steps, which include the placement of clamps to delineate the resection area, division of the rectum, and removal of the diseased segment. The remaining rectal or sigmoid tissue is then sutured to maintain continuity. A key aspect of this procedure is the creation of an ileal reservoir, which serves as a substitute for the rectum, allowing for the storage and passage of stool. Additionally, a loop ileostomy may be established to facilitate stool passage during the healing process of the newly formed pouch and ileoanal anastomosis. This complex surgical procedure aims to restore bowel function while addressing the underlying pathological condition.
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The procedure described by CPT® Code 45113 is indicated for various conditions affecting the rectum and surrounding structures. These indications may include:
The procedure involves several critical steps to ensure successful resection and reconstruction of the rectal area. The steps include:
After the completion of the procedure, patients typically require careful monitoring and post-operative care. This may include management of the ileostomy, monitoring for signs of infection, and ensuring proper healing of the anastomosis. Patients may also need to follow specific dietary guidelines to facilitate recovery and adapt to changes in bowel function. Follow-up appointments are essential to assess the healing process and address any complications that may arise.
| Short Descr | PARTIAL PROCTECTOMY | Medium Descr | PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR | Long Descr | Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 78 - Colorectal resection |
| 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related |
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| 1995-01-01 | Added | First appearance in code book in 1995. |
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