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The CPT® Code 46610 refers to a specific medical procedure known as anoscopy, which involves the examination of the anal canal and lower rectum using a specialized instrument called an anoscope. This procedure is particularly focused on the removal of a single tumor, polyp, or other lesion utilizing either hot biopsy forceps or bipolar cautery. The process begins with the insertion of the obturator into the anoscope, which is then introduced into the anus. The physician advances the scope using a twisting motion while the patient bears down, facilitating easier access to the anal canal. Once the obturator is removed, the eyepiece is attached to the anoscope, allowing for a clear view of the internal structures. The scope is then carefully withdrawn to inspect the mucosa for any abnormalities, such as tumors or polyps. In the context of this procedure, hot biopsy forceps are employed to simultaneously excise and cauterize the tissue, utilizing an insulated monopolar forceps that applies electrical current to achieve this dual function. Alternatively, bipolar cautery is used, which also employs electrical current but operates differently by directing the current between two points on the forceps tip. Both methods are primarily indicated for the removal of small polyps and the treatment of vascular ectasias, which are abnormal blood vessel formations. This procedure is essential for diagnosing and treating various conditions affecting the anal and rectal areas, ensuring that any lesions are effectively managed to prevent further complications.
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The procedure described by CPT® Code 46610 is indicated for the following conditions:
The procedure begins with the insertion of the obturator into the anoscope, which is then carefully introduced into the anus. The physician advances the anoscope using a twisting motion while the patient bears down, which helps to facilitate the insertion and positioning of the scope. Once the anoscope is adequately positioned, the obturator is removed, and the eyepiece is attached to the anoscope. This allows the physician to visualize the internal structures of the anal canal and lower rectum. The anoscope is then withdrawn slightly to enable a thorough inspection of the mucosa, where any tumors, polyps, or lesions can be identified. Upon locating the lesion, the physician employs either hot biopsy forceps or bipolar cautery for removal. Hot biopsy forceps are designed to simultaneously excise and cauterize the tissue, utilizing an insulated monopolar forceps that delivers electrical current to the targeted area. This method is effective for ensuring that the tissue is removed while minimizing bleeding. Alternatively, bipolar cautery can be used, which operates by passing electrical current between two points on the forceps tip, allowing for precise removal and cauterization of the lesion. Both techniques are particularly suited for small polyps and vascular ectasias, ensuring effective treatment during the procedure.
After the completion of the procedure, patients may be monitored for any immediate complications, such as bleeding or discomfort. It is essential to provide post-procedure care instructions, which may include recommendations for pain management and activity restrictions. Patients are typically advised to avoid strenuous activities for a short period following the procedure. Follow-up appointments may be scheduled to assess the site of the lesion removal and to ensure proper healing. Any abnormal findings during the procedure may necessitate further evaluation or treatment, depending on the physician's assessment.
| Short Descr | ANOSCOPY REMOVE LESION | Medium Descr | ANOSCOPY W/RMVL LESION CAUTERY | Long Descr | Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery | 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 | 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) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 77 - Proctoscopy and anorectal biopsy |
| 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). | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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