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The CPT® Code 45395 refers to a surgical procedure known as a complete proctectomy, which is performed using laparoscopic techniques. This procedure involves the removal of the rectum and surrounding tissues, and it is combined with the creation of a colostomy. The term "laparoscopy" indicates that the surgery is conducted through small incisions in the abdomen, utilizing a camera and specialized instruments to minimize trauma to the body compared to traditional open surgery. The procedure begins with the establishment of pneumoperitoneum, which is the introduction of gas into the abdominal cavity to create space for the surgeon to work. Following this, additional incisions are made to allow for the insertion of trocars, which are instruments that facilitate the introduction of surgical tools into the abdominal cavity. During the proctectomy, the sigmoid colon is carefully mobilized and retracted to expose the rectum, which is then detached from its attachments in the pelvic and abdominal regions. The inferior mesenteric artery and vein, which supply blood to the colon, are identified, ligated, and transected to ensure complete removal of the rectum. The procedure culminates with the creation of a colostomy, where a portion of the colon is brought out through the abdominal wall to form a stoma, allowing for waste to exit the body into a colostomy bag. This procedure is typically indicated for conditions such as rectal cancer, severe inflammatory bowel disease, or other significant rectal pathologies that necessitate the removal of the rectum and the establishment of an alternative route for waste elimination.
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The procedure described by CPT® Code 45395 is indicated for various medical conditions that necessitate the removal of the rectum and the establishment of a colostomy. These indications may include:
The procedure for CPT® Code 45395 involves several detailed steps to ensure the complete removal of the rectum and the creation of a colostomy. The process begins with the surgeon making a small incision near the umbilicus to insert a trocar, which allows for the establishment of pneumoperitoneum, creating a working space in the abdominal cavity. Additional portal incisions are made in the upper and lower quadrants of the abdomen, and more trocars are placed to facilitate the introduction of surgical instruments. Once the abdominal cavity is accessed, the surgeon inspects the area to assess the condition of the organs.
After the completion of the procedure, patients typically require monitoring for any complications related to the surgery. Post-operative care may include pain management, monitoring for signs of infection, and ensuring proper function of the colostomy. Patients will receive instructions on how to care for the stoma and manage the colostomy appliance. Recovery time can vary, but patients are generally advised to follow up with their healthcare provider to assess healing and address any concerns regarding their new colostomy. It is essential for patients to be educated on dietary modifications and lifestyle changes that may be necessary following the procedure.
| Short Descr | LAP REMOVAL OF RECTUM | Medium Descr | LAPS PROCTECTOMY ABDOMINOPERINEAL W/COLOSTOMY | Long Descr | Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy | 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 |
This is a primary code that can be used with these additional add-on codes.
| 49327 | Addon Code MPFS Status: Active Code APC N ASC N1 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) |
| 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). | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| 2006-01-01 | Added | First appearance in code book in 2006. |
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