Summary & Overview
CPT 46288: Fistula Excision with Flap Repair
CPT code 46288 denotes surgical excision of an anal fistula with repair of the remaining defect using local tissue flap coverage. This reconstructive anorectal procedure is clinically significant due to its use in complex or high transsphincteric and suprasphincteric fistulas, where preserving sphincter function and reducing recurrence risk are primary goals. Nationally, appropriate coding for complex fistula repairs affects surgical reimbursement, quality measurement, and specialty care utilization.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure and an overview of the payer landscape relevant to claims and coverage considerations. The publication summarizes common modifiers used with surgical codes, typical sites of service, and where available, benchmark considerations and policy updates that influence coverage for complex anorectal reconstructive procedures.
This resource aims to equip coding professionals, surgical clinicians, and policy analysts with a clear, nationally-focused description of the service represented by CPT code 46288, the typical clinical scenarios in which it is applied, and the payer audience most likely involved in coverage and reimbursement decisions. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 46288 describes a surgical procedure in which a provider excises an anal fistula and repairs the resulting defect by mobilizing and placing nearby tissue over the defect (flap repair). This technique is typically used for patients with high transsphincteric or suprasphincteric fistulas or for those with complicated fistula anatomy.
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Service type: Surgical fistula excision with flap repair (reconstructive anorectal surgery)
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Typical site of service: Ambulatory surgery center or hospital operating room for patients requiring operative anesthesia and specialized colorectal or general surgery care.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 34-year-old adult presenting with a complex anorectal fistula, often after recurrent perianal abscess or prior failed fistulotomy. The patient reports chronic drainage, intermittent pain, and occasional fecal soiling. Examination and preoperative imaging (endorectal ultrasound or MRI pelvis) confirm a high transsphincteric or suprasphincteric fistula with a primary tract and secondary extensions. Prior conservative measures (antibiotics, seton placement) may have been attempted.
The clinical workflow includes outpatient evaluation by a colorectal surgeon or general surgeon with expertise in anorectal procedures, diagnostic imaging to map the fistula, informed consent describing risks and alternatives, and scheduling for operative intervention. In the operating room under regional or general anesthesia, the surgeon excises the fistula tract and performs a flap repair (advancement flap or other local tissue flap) to close the internal opening and cover the defect, preserving sphincter function. Postoperative care includes wound care instructions, pain control, stool softeners, follow-up visits to assess healing, and management of any complications such as infection or recurrence.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the procedure requires substantially greater work than usual (e.g., extensive dissection, multiple tracts). |