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The procedure described by CPT® Code 45563 involves the exploration, repair, and presacral drainage for a rectal injury, specifically when a colostomy is also performed. This procedure is indicated in cases of penetrating injuries to the rectum, where the integrity of the rectal wall is compromised. The process begins with an abdominal exploration to identify the rectal injury, followed by controlling any bleeding that may be present. The rectal wound is then meticulously repaired using sutures to restore the normal anatomy. In instances where the injury necessitates a diversion of stool, a colostomy is created. This colostomy is typically fashioned from the sigmoid colon and serves to temporarily redirect fecal matter away from the rectum, allowing for healing. The colostomy can be performed using various techniques, including a loop colostomy, a loop colostomy with distal closure, or an end colostomy with a mucous fistula. After the abdominal procedure and the creation of the stoma, presacral drains are placed to facilitate drainage and prevent complications. The surgical approach includes making a curvilinear incision between the coccyx and the posterior margin of the anus, extending through the endopelvic fascia, and utilizing blunt dissection to access the presacral space and the site of the rectal injury. A drain is then inserted and secured to the perianal skin to ensure proper management of the surgical site.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 45563 is indicated for the management of penetrating injuries to the rectum. These injuries may arise from various causes, including trauma from accidents, surgical complications, or other forms of external force that compromise the rectal wall integrity. The primary goal of this procedure is to explore the injury, repair any damage, and manage potential complications such as bleeding or infection.
The procedure involves several critical steps to ensure effective management of the rectal injury. Each step is designed to address the injury comprehensively and safely.
After the completion of the procedure, patients are typically monitored for any signs of complications, such as infection or bleeding. The presence of presacral drains allows for effective management of any fluid accumulation. Patients may require additional care and follow-up appointments to assess the healing of the rectal repair and the colostomy site. Instructions regarding colostomy care, dietary modifications, and activity restrictions may also be provided to ensure optimal recovery.
| Short Descr | EXPLORATION/REPAIR OF RECTUM | Medium Descr | EXPL RPR & PRESACRAL DRG RECTAL INJ W/COLOSTOMY | Long Descr | Exploration, repair, and presacral drainage for rectal injury; 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 | 72 - Colostomy, temporary and permanent |
| 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). | 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. | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 1995-01-01 | Added | First appearance in code book in 1995. |
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