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The CPT® Code 46916 refers to the procedure for the destruction of lesions located in the anal region, specifically utilizing cryosurgery as the method of treatment. This procedure is indicated for various types of anal lesions, including but not limited to condyloma, papilloma, molluscum contagiosum, and herpetic vesicles. During the procedure, the physician evaluates the lesion to determine the most suitable method of destruction. Cryosurgery involves the application of extreme cold, typically using liquid nitrogen, to freeze the lesion, which leads to its destruction. This method may require multiple freeze-thaw cycles to ensure complete eradication of the lesion. Local anesthesia may be administered to manage discomfort during the procedure. The use of cryosurgery is one of several techniques available for lesion destruction, which also includes chemical destruction, electrodessication, laser surgery, and surgical excision, each with its own specific indications and procedural steps.
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The procedure described by CPT® Code 46916 is indicated for the treatment of various anal lesions. These include:
The procedure for CPT® Code 46916 involves several key steps to ensure effective destruction of the anal lesions through cryosurgery. The following procedural steps are typically followed:
Following the cryosurgery procedure coded under CPT® 46916, patients may experience some localized swelling, redness, or discomfort in the treated area. It is important for patients to follow any post-procedure care instructions provided by their physician, which may include keeping the area clean and dry, avoiding irritants, and monitoring for any signs of infection. The physician may schedule a follow-up appointment to evaluate the healing process and ensure that the lesion has been effectively destroyed. Recovery time can vary depending on the individual and the extent of the procedure, but most patients can expect to resume normal activities relatively quickly.
| Short Descr | CRYOSURGERY ANAL LESION(S) | Medium Descr | DSTRJ LESION ANUS SIMPLE CRYOSURGERY | Long Descr | Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery | Status Code | Active Code | Global Days | 010 - Minor Procedure | 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 | 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 OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 95 - Other non-OR lower GI therapeutic procedures |
| 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.) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GZ | Item or service expected to be denied as not reasonable and necessary | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | 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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