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The CPT® Code 45116 refers to a surgical procedure known as a partial proctectomy with anastomosis performed exclusively through a transsacral approach, specifically the Kraske type. This technique is characterized by the patient being positioned prone in a jack-knife position, which facilitates access to the rectum through the lower back. The procedure begins with an incision made at the midline of the back, starting approximately 2 cm above the anal verge and extending upwards for about 8-10 cm. This incision allows for the excision of the coccyx and resection of the two lower sacral segments, providing the necessary exposure to the distal segment of the rectum. Once the rectum is adequately mobilized, it is divided both above and below the diseased or injured segment, which is then removed. The remaining proximal and distal segments of the rectum are subsequently anastomosed in an end-to-end fashion, ensuring continuity of the bowel. After the anastomosis is completed, drains are placed to manage any potential fluid accumulation, and the transsacral incision is closed. This procedure is rarely performed due to its complexity and the specific indications that necessitate its use, making it a specialized surgical intervention within the field of colorectal surgery.
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The procedure described by CPT® Code 45116 is indicated for specific conditions affecting the rectum that may require surgical intervention. These indications include:
The procedure for CPT® Code 45116 involves several critical steps, all performed through the transsacral approach:
Post-procedure care following a partial proctectomy with anastomosis via the transsacral approach includes monitoring for complications such as infection, anastomotic leakage, and proper healing of the incision site. Patients may require pain management and should be monitored for bowel function as they recover. Follow-up appointments are essential to assess the surgical site and ensure that the anastomosis is functioning correctly. Additionally, dietary modifications may be recommended to facilitate recovery and minimize strain on the digestive system during the healing process.
| Short Descr | PARTIAL REMOVAL OF RECTUM | Medium Descr | PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY | Long Descr | Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) | 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 |
| 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). | 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. | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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