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Anoscopy with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery, or snare technique is a specialized medical procedure performed to treat abnormal growths within the anal canal. This procedure is indicated when lesions are present that cannot be effectively removed using standard techniques such as hot biopsy forceps, which utilize heat to excise tissue, or bipolar cautery, which employs electrical current for cutting and coagulation. The term 'ablation' refers to the process of destroying or removing tissue, and in this context, it typically involves the use of laser technology. The procedure begins with the insertion of an obturator into the anoscope, which is then introduced into the anus. The anoscope is advanced with a twisting motion while the patient bears down, allowing for better visualization and access to the lesions. Once the obturator is removed and the eyepiece is attached, the scope is carefully withdrawn to inspect the mucosa for any tumors, polyps, or lesions. The ablation process is initiated at the proximal margin of the identified lesion, and as the endoscope is retracted, the laser device is used to destroy the lesion completely. If multiple lesions are present, the procedure is repeated for each one until all have been adequately treated. This method is crucial for managing lesions that pose a risk of malignancy or cause significant symptoms, ensuring that patients receive effective care while minimizing the risk of complications associated with more invasive surgical techniques.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of anoscopy with ablation is indicated for the following conditions:
The procedure begins with the insertion of an obturator into the anoscope, which is then introduced into the anus. The clinician advances the anoscope using a twisting motion while the patient bears down, facilitating access to the anal canal. Once the anoscope is in position, the obturator is removed, and the eyepiece is attached to the scope. The clinician then carefully withdraws the scope to inspect the mucosa for any tumors, polyps, or lesions that may require treatment. Upon identifying the lesion, the ablation process is initiated. A laser device is delivered through the endoscope to the proximal margin of the lesion. Starting at this proximal margin, the clinician begins to ablate the lesion as the endoscope is retracted. The laser device traverses the entire lesion, effectively destroying it. If multiple tumors, polyps, or lesions are present, the clinician repeats the ablation process for each lesion until all have been adequately treated, ensuring thorough management of the identified abnormalities.
After the completion of the anoscopy with ablation procedure, patients may experience some discomfort or mild pain in the anal area, which is typically manageable with over-the-counter pain relief. It is important for patients to follow any specific post-procedure care instructions provided by their healthcare provider, which may include recommendations for dietary modifications, activity restrictions, and signs of complications to watch for, such as excessive bleeding or signs of infection. Follow-up appointments may be scheduled to monitor the healing process and assess for any recurrence of lesions. Overall, the expected recovery time is generally short, allowing patients to return to their normal activities relatively quickly, depending on individual circumstances and the extent of the procedure performed.
| Short Descr | ANOSCOPY | Medium Descr | ANOSCOPY ABLATION LESION | Long Descr | Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique | 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). | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2017-01-01 | Note | AMA Guidelines removed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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