© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 45114 refers to a partial proctectomy performed using both abdominal and transsacral approaches. A proctectomy is a surgical operation that involves the removal of part of the rectum, which is the final section of the large intestine leading to the anus. The term "partial" indicates that only a portion of the rectum is excised rather than the entire structure. The transsacral approach, although rarely utilized, involves accessing the rectum through an incision made in the lower back, specifically at the midline, which allows for direct visualization and manipulation of the rectal area. This approach is complemented by an abdominal incision, which facilitates access to the proximal segment of the rectum and potentially the sigmoid colon. The procedure is typically indicated for conditions affecting the rectum, such as tumors or severe inflammatory diseases, where removal of the affected segment is necessary to restore health and function. The surgical technique requires careful planning and execution to ensure proper anastomosis, which is the reconnection of the remaining segments of the rectum and colon after the diseased portion has been removed.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 45114 is indicated for specific conditions affecting the rectum that necessitate surgical intervention. These indications may include:
The procedure for CPT® Code 45114 involves several detailed steps, combining both transsacral and abdominal approaches to achieve the desired surgical outcome. The following steps outline the process:
Post-procedure care following a partial proctectomy with anastomosis involves monitoring the patient for any complications, such as infection or anastomotic leakage. Patients may require pain management and should be observed for signs of bowel function returning. Recovery may involve dietary modifications and gradual reintroduction of normal activities as tolerated. Follow-up appointments are essential to assess healing and ensure that the anastomosis is functioning properly. Additional considerations may include the need for further interventions or therapies depending on the underlying condition that necessitated the surgery.
| Short Descr | PARTIAL REMOVAL OF RECTUM | Medium Descr | PRCTECT PRTL W/ANAST ABDL & TRANSSAC APPROACH | Long Descr | Proctectomy, partial, with anastomosis; abdominal and transsacral approach | 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 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.