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Curettage or cautery of an anal fissure, including dilation of the anal sphincter, is a surgical procedure performed as a separate intervention. An anal fissure is defined as a painful tear or crack in the mucous membrane lining the anus, which can lead to significant discomfort and complications if not treated appropriately. In cases where the fissures become chronic, they may result in a narrowing or stricture of the anal sphincter, necessitating dilation to alleviate symptoms and restore normal function. The treatment of the fissure involves curettage, a technique that entails scraping the affected area to remove the damaged tissue and expose the healthy underlying mucosa. This process may be followed by cautery methods, which can include chemical cautery using agents such as silver nitrate or phenol in glycerine, or electrocautery, which applies heat through a high-frequency current delivered via a metal probe or needle. If a stricture is identified during the procedure, dilation is performed using a bougie, a flexible cylindrical instrument designed to stretch the narrowed area. It is important to note that CPT® Code 46940 is used for the initial procedure, while CPT® Code 46942 is designated for subsequent procedures related to this treatment.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of curettage or cautery of an anal fissure, including dilation of the anal sphincter, is indicated for the following conditions:
The procedure involves several key steps to effectively treat the anal fissure and any associated stricture:
After the procedure, patients may experience some discomfort, which can be managed with prescribed pain relief. It is essential to follow post-operative care instructions, which may include dietary modifications to ensure soft bowel movements and the use of topical treatments to promote healing. Patients should be monitored for any signs of complications, such as excessive bleeding or infection, and follow-up appointments should be scheduled to assess healing and the need for any further interventions.
| Short Descr | TREATMENT OF ANAL FISSURE | Medium Descr | CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ | Long Descr | Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent | 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) | 0 - 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 MPFS nonfacility PE RVUs. | 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 |
| QK | Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals | QS | Monitored anesthesia care service | 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.) | 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | 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.) | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period |
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| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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