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Anoscopy with dilation is a medical procedure aimed at treating strictures of the anus, which are narrowings that can occur due to various factors such as previous surgeries, radiation therapy, or inflammatory diseases. During this procedure, the anus is first visually inspected, and a digital rectal examination may be performed to assess the condition further. The process begins with the insertion of an obturator into the anoscope, which is then carefully introduced into the anus. The anoscope is advanced toward the stricture using a twisting motion while the patient is instructed to bear down, facilitating the passage of the instrument. Once the anoscope reaches the stricture, the obturator is removed, and an eyepiece is attached to allow for direct visualization. A guidewire is then advanced through the anoscope to a location just proximal to the stricture, ensuring precise placement. Following this, a balloon catheter is introduced over the guidewire and positioned within the stricture. The balloon is inflated to dilate the narrowed area and is held in place for a brief period before being deflated and removed. Alternatively, a bougie, which is a flexible cylindrical instrument, may be utilized to stretch the stricture by passing it through the narrowed passage. After the dilation process, the area is re-examined using the anoscope to confirm the success of the dilation and to check for any potential injuries to the anal tissue that may have occurred during the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of anoscopy with dilation is indicated for patients experiencing strictures of the anus. These strictures may arise from various underlying conditions, including:
The procedure of anoscopy with dilation involves several key steps that are performed to ensure effective treatment of the anal stricture.
After the completion of the anoscopy with dilation, patients may be monitored for any immediate complications. It is important to assess the area for any signs of injury or bleeding. Patients may experience some discomfort or mild pain following the procedure, which can typically be managed with over-the-counter pain relief. Instructions regarding activity restrictions and follow-up appointments will be provided to ensure proper recovery and monitoring of the treated stricture. Patients should be advised to report any unusual symptoms, such as increased pain, bleeding, or changes in bowel habits, to their healthcare provider promptly.
| Short Descr | ANOSCOPY AND DILATION | Medium Descr | ANOSCOPY W/DILATION | Long Descr | Anoscopy; with dilation (eg, balloon, guide wire, bougie) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic 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. | Endoscopic Base Code | 46600 Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 77 - Proctoscopy and anorectal biopsy |
| XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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. | 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. | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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