© Copyright 2025 American Medical Association. All rights reserved.
Proctopexy is a surgical procedure aimed at correcting rectal prolapse, a condition where the rectum protrudes through the anus. This specific procedure, identified by CPT® Code 45540, utilizes an abdominal approach to address the prolapse effectively. During the operation, a midline incision is made in the abdomen, allowing access to the sigmoid colon and rectum. The surgeon carefully dissects these structures away from the presacral fascia, which is the connective tissue located in front of the sacrum. This dissection enables the mobilization of the rectum and sigmoid colon, facilitating entry into the presacral space. Once the rectum is adequately mobilized, the prolapsed segment is reduced, and the portion of the colon that will be secured to the sacrum is identified. The final step involves suturing the rectum to the sacrum or sacral promontory, ensuring that it remains in its proper anatomical position. This procedure is critical for patients suffering from rectal prolapse, as it restores normal function and alleviates associated symptoms.
© Copyright 2025 Coding Ahead. All rights reserved.
Proctopexy (CPT® Code 45540) is indicated for the treatment of rectal prolapse, which may present with various symptoms and conditions. The following are the explicit indications for performing this procedure:
The proctopexy procedure involves several critical steps to ensure the successful correction of rectal prolapse. The following outlines the procedural steps as described:
Post-procedure care following a proctopexy involves monitoring the patient for any complications and ensuring proper recovery. Patients may experience some discomfort and will be advised on pain management strategies. It is essential to follow up with the healthcare provider to assess the surgical site and ensure that the rectum remains in its correct position. Patients may also receive instructions regarding dietary modifications and activity restrictions to promote healing and prevent strain on the surgical site. Regular follow-up appointments are crucial to monitor for any signs of recurrence of the prolapse or other complications.
| Short Descr | CORRECT RECTAL PROLAPSE | Medium Descr | PROCTOPEXY ABDOMINAL APPROACH | Long Descr | Proctopexy (eg, for prolapse); abdominal 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 | 96 - Other OR lower GI therapeutic procedures |
| 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. | 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 | CG | Policy criteria applied | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2006-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.