CPT 45915 Removal of Rectal Foreign Body Reimbursement | OpenPayer

Summary & Overview

CPT 45915: Removal of Rectal Foreign Body or Fecal Impaction Under Anesthesia

CPT code 45915 designates the surgical removal of a foreign body or fecal impaction from the rectum performed with the patient under anesthesia. Clinically, this code applies when manual or instrument-assisted extraction is required in a controlled anesthetic setting, distinguishing it from bedside or non-anesthetized interventions. Nationally, accurate use of this code affects procedural reporting, facility billing, and capture of resource intensity for rectal obstruction procedures.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, and common billing considerations associated with CPT code 45915. The publication summarizes expected use cases, payer coverage patterns, and common modifiers identified for this procedure. It also highlights benchmarking approaches and policy considerations relevant to procedure reporting and facility claims. The content is intended for healthcare billing professionals, practice managers, and policy analysts seeking a focused national perspective on coding and billing for rectal foreign body and fecal impaction removal under anesthesia.

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

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Billing Code Overview

CPT code 45915 describes the surgical removal of a foreign body or fecal impaction from the rectal canal performed with the patient under anesthesia. This procedure involves manual or instrument-assisted extraction of obstructing material from the rectum when less invasive measures are insufficient or contraindicated.

Service type: Surgical removal of rectal foreign body or fecal impaction under anesthesia
Typical site of service: Operating room or other setting where anesthesia is administered (inpatient or outpatient surgical suite)

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult presenting to the emergency department or operating room with a retained rectal foreign body or severe fecal impaction that cannot be safely removed awake. Patients often have acute rectal pain, bleeding, obstipation, or signs of obstruction. After triage and focused history, imaging (abdominal/ pelvic radiographs or CT) is used to localize the object or impaction and assess for perforation. The procedure 45915 is performed with the patient under anesthesia (general or monitored anesthesia care) to provide muscle relaxation and analgesia, enabling safe manual or instrument-assisted removal. Peri-procedural workflow includes informed consent, pre-anesthesia evaluation, anesthesia administration, operative removal of the foreign body or impacted stool, inspection for mucosal injury, possible hemostasis, and post-anesthesia recovery. Disposition ranges from same-day discharge with outpatient follow-up to admission if complications (perforation, ongoing bleeding, or sepsis) are present.

Coding Specifications

Modifier	Description	When to Use
`23`	Unusual anesthesia	Use when a procedure normally done without general anesthesia requires general anesthesia due to patient condition or procedure complexity.

Related Codes

CPT-45905-ANAL-CANAL-DILATION-STRICTURE

CPT 45905: Manual Dilation of Anal Canal Stricture

CPT-45900-RECTAL-PROLAPSE-REDUCTION-UNDER-ANESTHESIA

CPT 45900: Reduction of Rectal Prolapse, Manual Under Anesthesia

CPT-45910-RECTAL-STRICTURE-DILATION-MANUAL

CPT 45910: Manual Dilation of Rectal Stricture

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Taxonomy Code	Specialty	Notes
207P00000X	Proctology (Colorectal Surgery)	Colorectal surgeons commonly manage complex rectal foreign bodies and fecal impaction requiring anesthesia.
207L00000X	General Surgery	General surgeons often perform rectal foreign body extractions and manage complications.
2080P0003X	Gastroenterology	Gastroenterologists may perform endoscopic-assisted removal or evaluation but typically under sedation; involvement when endoscopic techniques are used.
2086S0121X	Emergency Medicine	Emergency physicians identify, stabilize, and arrange operative removal; may perform bedside attempts if safe.
207RH0000X	Obstetrics & Gynecology	Gynecologic surgeons occasionally involved when proximity to pelvic organs or combined procedures are required.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K59.0`	Constipation	Severe constipation can progress to fecal impaction requiring manual disimpaction under anesthesia.
`K56.6`	Other and unspecified intestinal obstruction	Obstructive symptoms from impacted stool or large foreign body may necessitate operative removal.
`T18.0`	Foreign body in alimentary tract	Directly relevant when a rectal foreign body is present and requires removal.
`K62.5`	Hemorrhage of anus and rectum	Mucosal injury or removal-related bleeding may be present and addressed during the procedure.
`K58.0`	Irritable bowel syndrome with diarrhea	Included when rectal foreign body insertion is associated with altered bowel habits; less common.
`R19.4`	Change in bowel habit	Symptom code used when obstruction or impaction presents with altered bowel pattern.
`A09`	Infectious gastroenteritis and colitis, unspecified	Enteric infection can complicate fecal impaction and influence peri-procedural management.
`K65.0`	Acute peritonitis	Used when perforation with peritonitis occurs as a complication requiring surgical management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`00920`	Anesthesia for procedures on lower abdomen; not otherwise specified	Anesthesia code commonly reported when general or regional anesthesia is provided for rectal foreign body removal (anesthesia is required for `45915`).
`45380`	Colonoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing	May be performed before or after removal to evaluate mucosa for injury or to attempt endoscopic removal if feasible.
`45382`	Colonoscopy, flexible; with directed submucosal injection, localized treatment, or removal of foreign body	Used when endoscopic techniques are used to assist removal or treat mucosal injury in the colon/rectum.
`44970`	Abdominal laparotomy, exploratory; with or without biopsy(s)	Used if transabdominal exploration becomes necessary because of perforation or inability to retrieve the foreign body transanally.
`99223`	Initial hospital care, typically 70 minutes or more	Common evaluation and management code for admission after complicated extraction or postoperative care; documents medically necessary inpatient management.