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The procedure described by CPT® Code 45562 involves the exploration and repair of a rectal injury, along with the placement of presacral drains. This procedure is typically indicated in cases of penetrating injuries to the rectum, where the integrity of the rectal wall is compromised. During the operation, the abdomen is surgically opened to allow for direct visualization and assessment of the injury. Once the rectal injury is identified, the surgeon takes steps to control any bleeding that may be present. The next critical step involves the repair of the rectal wound, which is accomplished using sutures to restore the normal anatomy and function of the rectum. In certain cases, depending on the severity and nature of the injury, a colostomy may be necessary to divert stool away from the rectum temporarily. This diversion is crucial for allowing the rectal repair to heal without the stress of stool passage. If a colostomy is performed, it is typically created in the sigmoid colon, and various techniques may be employed, including loop colostomy, loop with distal closure, or an end colostomy with a mucous fistula. Following the repair of the rectal injury and any necessary colostomy creation, presacral drains are placed to facilitate the drainage of any potential fluid accumulation in the presacral space. The placement of these drains is achieved through a curvilinear incision made between the coccyx and the posterior margin of the anus, which is then extended through the endopelvic fascia. Blunt dissection is utilized to access the presacral space, allowing the surgeon to reach the site of the rectal injury. A drain is inserted to the level of the injury and secured to the perianal skin to ensure proper drainage and minimize the risk of complications.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 45562 is indicated for the following conditions:
The procedure begins with the patient being placed under appropriate anesthesia. The surgeon makes an incision in the abdomen to gain access to the abdominal cavity. This allows for exploration of the area to identify any injuries, particularly to the rectum. Once the abdomen is opened, the surgeon carefully examines the rectal area to locate the injury. Upon identification of the rectal injury, the surgeon takes immediate steps to control any bleeding that may be occurring, which is critical to prevent further complications.
After controlling the bleeding, the next step involves the repair of the rectal wound. The surgeon uses sutures to close the injury, restoring the integrity of the rectal wall. Depending on the nature and severity of the injury, the surgeon may determine that a colostomy is necessary. This procedure involves diverting stool away from the rectum to allow for proper healing. If a colostomy is indicated, it is typically performed in the sigmoid colon. The surgeon may choose from various colostomy techniques, including a loop colostomy, a loop colostomy with distal closure, or an end colostomy with a mucous fistula, based on the specific clinical scenario.
Following the repair of the rectal injury and any colostomy creation, the surgeon proceeds to place presacral drains. This is done to prevent fluid accumulation in the presacral space, which could lead to complications. The placement of the drains involves making a curvilinear incision between the coccyx and the posterior margin of the anus. The incision is then extended through the endopelvic fascia to access the presacral space. Using blunt dissection, the surgeon carefully opens this space and continues the dissection until reaching the site of the rectal injury. A drain is then inserted to the level of the injury and secured to the perianal skin to ensure effective drainage.
After the completion of the procedure, the patient will be monitored for any signs of complications, such as infection or bleeding. The presacral drains will remain in place for a period to facilitate drainage and will be removed once the surgeon determines that it is safe to do so. The patient may require additional care and monitoring, especially if a colostomy was performed, as they will need education on stoma care and management. Recovery will vary based on the extent of the injury and the complexity of the procedure, and follow-up appointments will be necessary to assess healing and address any concerns.
| Short Descr | EXPLORATION/REPAIR OF RECTUM | Medium Descr | EXPL RPR & PRESACRAL DRG RECTAL INJURY | Long Descr | Exploration, repair, and presacral drainage for rectal injury; | 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). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 56 | Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number. | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2010-01-01 | Changed | Code description changed. |
| 1995-01-01 | Added | First appearance in code book in 1995. |
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