CPT® Code 45990

The CPT® Code 45990 refers to a surgical anorectal examination that necessitates the use of anesthesia, which can be general, spinal, or epidural. While anesthesia is not commonly required for standard anorectal examinations, it becomes essential in cases where patients experience significant discomfort or exhibit extreme anxiety regarding the procedure. This examination is primarily conducted to diagnose underlying issues causing pain in the anorectal area. During the procedure, the patient is typically positioned in a left lateral or Sim's position to facilitate access and visualization of the perineal region. The physician begins by visually inspecting the area for any lesions, fissures, hemorrhoids, drainage, or other abnormalities that may be present. Following the visual inspection, a digital examination is performed to assess for any masses or areas of fluctuance, which could suggest the presence of an abscess. Additionally, the use of an anoscope or proctoscope equipped with a sufficient light source allows for a more detailed visualization of the anal canal and distal rectum, enabling the physician to identify any lesions, masses, fistulas, or other abnormalities that may require further investigation or intervention.