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The CPT® Code 45160 refers to the surgical procedure involving the excision of a rectal tumor through a proctotomy, utilizing either a transsacral or transcoccygeal approach. This procedure is indicated when a tumor is present in the rectal area, necessitating surgical intervention for removal. The approach begins with an incision made along the midline of the back, starting approximately 2 cm above the anal verge and extending upwards for about 8 to 10 cm. This incision allows access to the rectum by excising the coccyx and resecting the lower sacral segments as required for adequate exposure. Once the rectum is accessible, an incision is made directly at the tumor site, enabling the surgeon to excise the tumor along with a margin of healthy tissue to ensure complete removal. To confirm that the excised margins are clear of cancerous cells, frozen sections are obtained during the procedure. The excised specimen is then sent to a laboratory for pathological evaluation, which is also separately reportable. After the tumor removal, the rectum is repaired with sutures, and the initial incision is closed, completing the procedure. This method is distinct from other excision techniques, such as those described in CPT® Codes 45171 and 45172, which utilize a transanal approach for tumor removal.
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The procedure described by CPT® Code 45160 is indicated for the removal of rectal tumors that may pose a risk to the patient's health. The specific indications for this procedure include:
The procedure for excising a rectal tumor via CPT® Code 45160 involves several critical steps, which are detailed as follows:
Post-procedure care following the excision of a rectal tumor via CPT® Code 45160 typically involves monitoring the patient for any complications related to the surgery. Patients may experience pain at the incision site, which can be managed with appropriate analgesics. It is essential to monitor for signs of infection, such as increased redness, swelling, or discharge from the incision site. Additionally, patients may require follow-up appointments to assess healing and to discuss the results of the pathological evaluation of the excised tumor. Depending on the findings, further treatment or surveillance may be necessary. Patients are usually advised on dietary modifications and bowel care to promote recovery and prevent complications during the healing process.
| Short Descr | EXCISION OF RECTAL LESION | Medium Descr | EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL | Long Descr | Excision of rectal tumor by proctotomy, transsacral or transcoccygeal 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 | Hospital Part B services paid through a comprehensive APC | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 78 - Colorectal resection |
| 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. | 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 |
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| 2011-01-01 | Changed | Guideline information changed. |
| Pre-1990 | Added | Code added. |
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