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Sphincteroplasty, specifically CPT® Code 46760, refers to a surgical procedure aimed at repairing the anal sphincter in adults who experience incontinence. This condition may arise due to various factors, including traumatic injuries to the anus or perineum, complications following hemorrhoidectomy, or surgical interventions for rectal prolapse or tumors. The procedure involves the use of a muscle transplant, typically the gracilis muscle, which is harvested from the thigh. The surgical approach includes making incisions to access the gracilis muscle, which is then carefully dissected and prepared for transplantation. The muscle is subsequently positioned to encircle the anus, providing support and restoring function. This procedure is critical for patients suffering from anal incontinence, as it aims to enhance their quality of life by improving bowel control and reducing involuntary leakage.
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The procedure of anal sphincteroplasty using muscle transplant (CPT® Code 46760) is indicated for adults experiencing incontinence due to various underlying conditions. The following are specific indications for this surgical intervention:
The surgical procedure for anal sphincteroplasty using muscle transplant involves several detailed steps to ensure proper repair and restoration of function. The following outlines the procedural steps:
After the anal sphincteroplasty procedure, patients can expect a recovery period that may involve monitoring for complications such as infection or bleeding. Post-operative care typically includes pain management and instructions for activity restrictions to promote healing. Patients may also be advised on dietary modifications to ease bowel movements and reduce strain during recovery. Follow-up appointments are essential to assess the surgical site, evaluate the success of the procedure, and address any concerns that may arise during the healing process.
| Short Descr | REPAIR OF ANAL SPHINCTER | Medium Descr | SPHINCTEROPLASTY ANAL MUSCLE TRANSPLANT | Long Descr | Sphincteroplasty, anal, for incontinence, adult; muscle transplant | 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 | 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 96 - Other 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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