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Sphincteroplasty, specifically coded as CPT® 46751, is a surgical procedure aimed at addressing anal or fecal incontinence in children. This condition arises from damage or weakening of the anal sphincters, which can be either the external or internal sphincter, or may result from rectal prolapse. Anal incontinence is characterized by the inability to retain stool within the rectum, leading to involuntary leakage. In adults, this issue is often due to traumatic injuries such as tears or lacerations, while in children, it is frequently linked to congenital anomalies present from birth. The procedure involves a meticulous surgical approach where the perineal area is first cleansed, followed by the administration of a local anesthetic and a vasoconstrictor to minimize bleeding at the surgical site. A curvilinear incision is then made parallel to the external sphincter, allowing the surgeon to dissect the anal mucosa away from any scar tissue and the underlying sphincter muscles. The dissection is carefully extended up to the levator ani muscle, and any scar tissue present is excised. To restore function, the muscle ends may be overlapped to decrease the anal diameter, and both the internal and external sphincters are repaired using sutures. Finally, the overlying mucosa and skin are also sutured to complete the procedure. It is important to note that CPT® 46751 is specifically designated for use in pediatric cases, while CPT® 46750 is the corresponding code for sphincteroplasty performed on adults.
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The sphincteroplasty procedure, coded as CPT® 46751, is indicated for the treatment of anal or fecal incontinence in children. This condition may arise from various underlying issues, including:
The sphincteroplasty procedure involves several critical steps to effectively repair the anal sphincters and restore continence. The steps are as follows:
After the sphincteroplasty procedure, patients are typically monitored for any immediate complications. Post-operative care may include pain management and instructions for activity restrictions to promote healing. Follow-up appointments are essential to assess the surgical site and ensure proper recovery. Patients may also receive guidance on dietary modifications and bowel management strategies to support continence as they heal. It is important for healthcare providers to monitor for any signs of infection or complications during the recovery period.
| Short Descr | REPAIR OF ANAL SPHINCTER | Medium Descr | SPHNCTROP ANAL INCONTINENCE/PROLAPSE CHLD | Long Descr | Sphincteroplasty, anal, for incontinence or prolapse; child | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 96 - Other OR lower GI therapeutic procedures |
| 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). |
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| Pre-1990 | Added | Code added. |
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