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Official Description

Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Anoscopy is a medical procedure that involves the examination of the anal canal and lower rectum using a specialized instrument known as an anoscope. This procedure is particularly important for diagnosing and treating various conditions affecting the anal region. During anoscopy, the obturator is first inserted into the anoscope, which is then introduced into the anus. The physician advances the anoscope using a twisting motion while the patient bears down, facilitating easier insertion. Once the anoscope is in place, the obturator is removed, and an eyepiece is attached to allow for direct visualization. The physician carefully withdraws the scope to inspect the mucosa for any abnormalities, such as lesions or sources of bleeding. In cases where bleeding is identified, various techniques can be employed to control it. These techniques may include the use of thermal modalities, such as bipolar or unipolar cautery, or a heater probe, which apply heat directly to the bleeding site to promote coagulation. Additionally, an injection of epinephrine may be administered to constrict blood vessels and help stop the bleeding. Non-contact methods, such as YAG laser coagulation and argon plasma coagulation, are also available for coagulating the bleeding site. In some instances, mechanical methods like staples or hemoclips may be utilized to approximate the edges of a tear or laceration, further aiding in the control of bleeding. Overall, anoscopy with control of bleeding is a critical procedure that combines diagnostic and therapeutic elements to manage conditions affecting the anal canal and lower rectum.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure of anoscopy with control of bleeding is indicated for various conditions that may lead to bleeding in the anal canal or lower rectum. These indications include:

  • Rectal Bleeding The presence of blood in the stool or from the rectum, which may indicate underlying conditions such as hemorrhoids, anal fissures, or more serious pathologies.
  • Anal Fissures Tears in the lining of the anal canal that can cause significant pain and bleeding during bowel movements.
  • Hemorrhoids Swollen blood vessels in the rectal area that can become inflamed and bleed.
  • Polyps or Tumors Abnormal growths that may be present in the anal canal or rectum, which can lead to bleeding and require further evaluation.
  • Infection or Inflammation Conditions such as proctitis that may cause bleeding and discomfort in the anal region.

2. Procedure

The procedure of anoscopy with control of bleeding involves several key steps that ensure effective examination and treatment. The following procedural steps are typically followed:

  • Step 1: Preparation The patient is positioned comfortably, and the area is prepared for the procedure. This may include ensuring the patient is relaxed and providing any necessary instructions for bearing down during the procedure.
  • Step 2: Insertion of the Anoscope The obturator is inserted into the anoscope, which is then gently introduced into the anus. The physician advances the anoscope using a twisting motion while the patient bears down, facilitating easier insertion into the anal canal.
  • Step 3: Visualization Once the anoscope is in place, the obturator is removed, and an eyepiece is attached. The physician then carefully withdraws the anoscope to inspect the mucosa for any abnormalities, such as lesions or sources of bleeding.
  • Step 4: Identification of the Bleeding Site The physician identifies the specific site of bleeding during the inspection. This step is crucial for determining the appropriate method of control.
  • Step 5: Control of Bleeding Various techniques are employed to control the bleeding. This may include the application of a contact thermal modality, such as bipolar or unipolar cautery, or a heater probe, directly to the bleeding point. Pressure is applied along with heat to promote coagulation. Alternatively, an injection of epinephrine may be administered to constrict blood vessels and assist in stopping the bleeding.
  • Step 6: Use of Non-Contact Methods If necessary, non-contact methods such as YAG laser coagulation or argon plasma coagulation may be utilized to coagulate the bleeding site without direct contact.
  • Step 7: Mechanical Approaches In cases of tears or lacerations, staples or hemoclips may be used to approximate the margins, further aiding in the control of bleeding.

3. Post-Procedure

After the completion of the anoscopy with control of bleeding, the patient may be monitored for any immediate complications or adverse effects. It is important to assess the effectiveness of the bleeding control measures employed during the procedure. Patients may experience some discomfort or minor bleeding post-procedure, which should be monitored. Instructions regarding activity restrictions, dietary modifications, and signs of complications to watch for should be provided to the patient. Follow-up appointments may be scheduled to ensure proper healing and to address any ongoing concerns related to the initial condition that necessitated the procedure.

Short Descr ANOSCOPY CONTROL BLEEDING
Medium Descr ANOSCOPY CONTROL BLEEDING
Long Descr Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
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
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).
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.)
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.
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).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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.
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.)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GC This service has been performed in part by a resident under the direction of a teaching physician
LT Left side (used to identify procedures performed on the left side of the body)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2011-01-01 Changed Short description changed.
2002-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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