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Official Description

Dilation of rectal stricture (separate procedure) under anesthesia other than local

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 45910 refers to the procedure of dilation of a rectal stricture, which is performed under anesthesia other than local anesthesia. A rectal stricture is a narrowing of the rectum that can lead to difficulties in bowel movements and other complications. This procedure aims to alleviate these issues by widening the constricted area. The dilation can be achieved through manual techniques, similar to those described in CPT® Code 45905, or by utilizing specialized instruments such as a balloon dilator. In the balloon dilation method, fluoroscopic guidance is often employed to ensure accurate placement and effective treatment of the stricture. The procedure involves the introduction of a feeding catheter into the rectum, which may be used to inject a contrast agent that helps visualize the stricture. Following this, a guidewire is advanced through the catheter to facilitate the placement of a balloon catheter, which is then inflated to expand the narrowed area. The inflation and deflation of the balloon are repeated as necessary to achieve the desired dilation, ultimately improving the patient's ability to pass stool and enhancing their quality of life.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The dilation of rectal stricture (CPT® Code 45910) is indicated for patients experiencing symptoms related to a narrowed rectum, which may include:

  • Difficulty with bowel movements Patients may struggle to pass stool due to the constriction, leading to discomfort and potential complications.
  • Rectal pain The stricture can cause significant pain during bowel movements or at rest.
  • Constipation A narrowed rectum can contribute to chronic constipation, making it difficult for patients to have regular bowel movements.
  • Rectal bleeding Strictures may lead to trauma in the rectal area, resulting in bleeding during bowel movements.

2. Procedure

The procedure for dilation of a rectal stricture involves several key steps, which may be performed manually or with the aid of a balloon dilator:

  • Step 1: Anesthesia Induction The procedure begins with the induction of anesthesia, ensuring the patient is comfortable and pain-free during the intervention. Anesthesia other than local is utilized to facilitate the procedure.
  • Step 2: Manual Dilation (if applicable) In cases where manual dilation is performed, the physician lubricates the anus and inserts two gloved fingers of the left hand into the anus. The physician then uses the right hand to insert the gloved index finger, applying gentle pressure to locate the constricting band within the sphincter. The physician continues to apply pressure along the band to release it, gradually inserting additional fingers until the desired dilation is achieved.
  • Step 3: Balloon Dilation If balloon dilation is chosen, a feeding catheter is introduced into the rectum. A contrast agent may be injected through the catheter to outline the stricture for better visualization. The catheter is positioned at or across the stricture orifice, and a guidewire is advanced through the catheter and beyond the stricture. The catheter is then removed, and a balloon catheter is advanced over the guidewire and positioned within the stricture.
  • Step 4: Balloon Inflation The guidewire is removed, and the balloon is inflated using contrast media. This inflation is maintained for 3-5 minutes to allow for effective dilation of the stricture. The balloon is then deflated, and the inflation and deflation process is repeated as necessary until the desired dilation is achieved.
  • Step 5: Completion Once the desired dilation is accomplished, the balloon catheter is removed, concluding the procedure.

3. Post-Procedure

After the dilation of the rectal stricture, patients may require monitoring for any immediate complications. Post-procedure care typically includes instructions for managing discomfort, monitoring for rectal bleeding, and ensuring proper bowel function. Patients may be advised to follow a specific diet or use stool softeners to facilitate bowel movements as they recover. Follow-up appointments may be necessary to assess the effectiveness of the procedure and to determine if further interventions are needed.

Short Descr DILATION OF RECTAL NARROWING
Medium Descr DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL
Long Descr Dilation of rectal stricture (separate procedure) under anesthesia other than local
Status Code Active Code
Global Days 010 - Minor Procedure
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) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
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) P5E - Ambulatory procedures - 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).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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.)
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.)
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
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
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