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The CPT® Code 46285 refers to the surgical treatment of an anal fistula, specifically during the second stage of the procedure, which can involve either a fistulectomy or a fistulotomy. An anal fistula is defined as an abnormal connection between two epithelial surfaces, typically occurring in the anal region. The procedure begins with the identification of the fistula tract, which may involve the use of a probe or suture to locate the internal opening of the fistula from the external opening. Once the tract is identified, the surgical approach can either involve incising and opening the fistula tract (fistulotomy) to promote healing from the inside out or excising the entire fistula tract (fistulectomy). It is important to note that different codes are used for various types of anal fistulas based on their anatomical location and complexity. For instance, CPT® Code 46270 is designated for subcutaneous anal fistulas, while CPT® Code 46275 is used for intersphincteric fistulas. More complex fistulas, such as transsphincteric, suprasphincteric, or extrasphincteric fistulas, which require more extensive dissection, are coded with CPT® Code 46280. In cases where an anal seton is placed, a non-absorbable suture material is inserted into the external opening of the fistula tract, passed through the internal opening, and then pulled back out of the anal canal. This seton can be left loose for drainage and fibrosis or can be a cutting type seton, which gradually opens the fistulous tract over time. The second stage of the procedure, represented by CPT® Code 46285, is performed to further address the fistula after an initial healing period, thereby reducing the risk of incontinence, especially when the fistula tract traverses the anal sphincter. This two-stage approach allows for a more controlled and safer surgical intervention.
© Copyright 2025 Coding Ahead. All rights reserved.
The surgical treatment of anal fistula, specifically the second stage of the procedure represented by CPT® Code 46285, is indicated for patients who present with an anal fistula that has not adequately healed following an initial surgical intervention. The indications for this procedure include:
The procedure for CPT® Code 46285 involves several critical steps to ensure the effective treatment of the anal fistula. The steps are as follows:
Following the second stage of the anal fistula treatment, patients can expect specific post-procedure care and recovery considerations. It is essential to monitor the surgical site for signs of infection or complications. Patients are typically advised to maintain good hygiene in the anal area and may be prescribed pain management medications to alleviate discomfort. Follow-up appointments are crucial to assess healing and to determine if further interventions are necessary. The expected recovery time may vary based on the complexity of the fistula and the individual patient's healing process. Patients should be informed about potential changes in bowel habits and the importance of reporting any unusual symptoms to their healthcare provider.
| Short Descr | REMOVE ANAL FIST 2 STAGE | Medium Descr | SURG TX ANAL FISTULA 2ND STAGE | Long Descr | Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage | 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 | 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). | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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