Summary & Overview
CPT 45541: Perineal Rectal Prolapse Repair with Mesh and Sutures
CPT code 45541 denotes a perineal approach to repair rectal prolapse using sutures and mesh. This operative code captures a specific surgical technique performed through an incision between the anus and scrotum in males or between the anus and vulva in females. The code is relevant nationally as it identifies procedures for symptomatic rectal prolapse that may be managed in inpatient or outpatient surgical settings and informs surgical case mix, resource use, and procedural reporting.
Key payers included in this overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, expectations for typical sites of service, and what the code represents for billing and encounter classification. The publication outlines benchmarks and common billing practices where available, highlights relevant policy and coverage considerations that affect national reimbursement and utilization patterns, and situates the procedure within surgical service lines for colorectal and general surgery. Data elements not provided in the input, such as specific ICD-10 diagnoses, payer-specific coverage rules, and detailed taxonomies, are noted as not available in the input.
Billing Code Overview
CPT code 45541 describes a surgical procedure to repair rectal prolapse through a perineal incision. In this service the provider makes an incision between the anus and scrotum in a male patient or between the anus and the vulva in a female patient, and performs repair using sutures and mesh.
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Service type: Perineal rectal prolapse repair with mesh and sutures
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Typical site of service: Operating room or ambulatory surgical center, performed by a qualified surgeon
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult presenting with full-thickness rectal prolapse, often with fecal incontinence, obstructed defecation, mucus discharge, or recurrent protrusion of rectal tissue through the anal verge. The patient may have a history of chronic straining, pelvic floor weakness, prior pelvic surgery, or neurologic disorders. Evaluation includes history and physical exam with proctologic inspection, anorectal manometry, defecography, and colonoscopy as indicated to exclude other pathology.
Surgical workflow for 45541 involves preoperative assessment, informed consent, bowel preparation when indicated, general or regional anesthesia, and perioperative antibiotics. The surgeon performs a perineal incision between the anus and scrotum in males or between the anus and vulva in females, reduces the prolapse, and secures the rectum with sutures and prosthetic mesh to restore fixation and prevent recurrence. Postoperative care includes pain control, stool softeners, wound care, and follow-up visits to monitor healing and continence outcomes.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when reporting only the surgeon’s professional service separate from technical facility charges (rare for surgical procedures billed by the operating practitioner). |