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The CPT® Code 46060 refers to the surgical procedure involving the incision and drainage of an ischiorectal or intramural abscess, which may also include a fistulectomy or fistulotomy. An ischiorectal abscess is a localized collection of pus that occurs in the ischiorectal space, a wedge-shaped area situated between the ischial tuberosity and the obturator internus muscle on one side, and the external anal sphincter and levator ani muscle on the other. This type of abscess can be unilateral or may extend posteriorly, potentially forming a horseshoe abscess that encircles the anal region. An intramural abscess, on the other hand, is found within the wall of the anal or rectal tissue. The formation of a fistula, which is an abnormal connection between two epithelial surfaces, typically occurs when an abscess ruptures, leading to the need for surgical intervention. The procedure begins with a digital rectal examination to identify the abscess and the associated fistula tract. A surgical incision is then made to allow for drainage and thorough inspection of the abscess cavity, which may involve breaking up any loculations present. The procedure may conclude with the placement of a drain or packing the incision, followed by the opening or excision of the fistula tract. Additionally, a seton may be placed to facilitate drainage or promote healing through controlled fibrosis, depending on the specific needs of the patient.
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The procedure described by CPT® Code 46060 is indicated for the management of specific conditions related to ischiorectal and intramural abscesses. The following are the primary indications for performing this procedure:
The procedure for CPT® Code 46060 involves several critical steps to ensure effective management of the abscess and associated fistula. The following outlines the procedural steps:
Post-procedure care for patients undergoing the incision and drainage of ischiorectal or intramural abscesses includes monitoring for signs of infection, managing pain, and ensuring proper wound care. Patients may be advised on how to care for the incision site, including keeping it clean and dry. Follow-up appointments are essential to assess healing and determine if further intervention is necessary, especially if a seton has been placed. The expected recovery time may vary based on the extent of the procedure and the patient's overall health, but patients should be informed about potential complications such as recurrence of the abscess or issues related to the fistula.
| Short Descr | INCISION OF RECTAL ABSCESS | Medium Descr | I&D ISCHIORCT/INTRAMURAL ABSC W/WO SETON | Long Descr | Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton | 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) | 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 | Hospital Part B services paid through a comprehensive APC | 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 | 2 | 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.) | 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.) | 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). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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