CPT® Code 46070

1. Indications

The procedure associated with CPT® Code 46070 is indicated for infants diagnosed with a congenital anal septum. This condition may present with various symptoms, including:

• Abnormal bowel movements Infants may experience difficulty in passing stool due to the obstruction created by the septum.
• Signs of discomfort Infants may exhibit signs of pain or discomfort during attempts to defecate.
• Failure to thrive In some cases, the inability to pass stool can lead to nutritional deficiencies and growth issues.

2. Procedure

The procedure for CPT® Code 46070 involves several critical steps to ensure the successful division of the anal septum. The steps are as follows:

• Step 1: Anesthesia Administration The infant is placed under appropriate anesthesia to ensure comfort and pain management during the procedure.
• Step 2: Inspection of the Anus The surgeon carefully inspects the anal region to assess the extent and nature of the congenital anal septum. This step is crucial for planning the incision and ensuring that the procedure addresses the specific anatomical issues present.
• Step 3: Incision of the Septum Once the inspection is complete, the surgeon proceeds to sharply incise the septum. This incision is made with precision to create a single tubular anal canal, effectively correcting the anatomical abnormality.
• Step 4: Hemostasis and Closure After the septum is incised, the surgeon ensures that there is no excessive bleeding (hemostasis) before closing the incision site. The area may be sutured or left to heal naturally, depending on the surgeon's assessment.

3. Post-Procedure

Following the procedure, the infant will require monitoring for any signs of complications, such as infection or excessive bleeding. Post-operative care may include pain management and ensuring the infant is able to pass stool normally. Parents or caregivers will be provided with instructions on how to care for the surgical site and what signs to watch for that may indicate complications. Follow-up appointments will be necessary to assess healing and ensure that the anal canal is functioning properly.