Summary & Overview
CPT 45562: Exploratory Rectal Repair with Presacral Drainage
CPT code 45562 denotes an open surgical exploration and repair of rectal injury with drainage of presacral or presacral-adjacent abscess or fluid. This code captures procedures where the lower abdomen or perineal region is incised to identify and repair rectal defects and to evacuate collections anterior to the sacrum. Nationally, accurate use of this code is important for hospital billing, surgical casemix reporting, and quality monitoring of complex anorectal interventions.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides an overview of clinical context for 45562, typical settings of care, and the operational implications for hospital surgical services. Readers will find benchmarks for utilization and payment where available, coding guidance on procedure documentation essentials, and summaries of relevant policy updates affecting surgical billing for rectal repair and presacral drainage. The report also highlights common billing modifiers and situational considerations for inpatient versus outpatient coding. Data not available in the input are noted where applicable.
Billing Code Overview
CPT code 45562 describes an open surgical procedure in which the provider makes an incision in the lower abdominal or perineal area to inspect the rectum for injury, repair any identified rectal wounds, and drain abscesses or collections in the presacral space or anterior to the sacrum. This procedure is typically categorized as an abdominal/perineal exploratory and rectal repair with presacral drainage.
Service type: Surgical — abdominal/perineal exploration and rectal repair
Typical site of service: Operating room or surgical suite; may occur in an inpatient or other acute care hospital setting
Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.
Clinical & Coding Specifications
Clinical Context
A 38-year-old patient presents to the emergency department after a pelvic fracture sustained in a motor vehicle collision with perineal pain, rectal bleeding, and tender presacral swelling on exam. The surgical team evaluates for possible rectal injury and presacral abscess. Imaging (CT pelvis) suggests a presacral fluid collection and concern for rectal wall disruption. The patient is taken to the operating room for an exploratory incision of the lower abdomen to inspect the rectum, identify and repair any rectal injury, and drain the presacral abscess or fluid collection. Intraoperative steps include lower midline or Pfannenstiel incision as indicated, exposure of the rectum, direct inspection and primary repair of any full-thickness rectal laceration, presacral space drainage with placement of drains, and irrigation. Postoperative care includes wound and drain management, antibiotics, tetanus status review, and monitoring for sepsis or fecal diversion needs. Typical providers include colorectal surgeons, general surgeons, or trauma surgeons performing this procedure in an operating room setting under general anesthesia. Typical place of service is an inpatient operating room or emergency surgery suite, with postoperative recovery on a surgical ward or intensive care unit as clinically indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the work required is substantially greater than typically required for the procedure (extensive adhesiolysis, unexpected complexity). |