Summary & Overview
CPT 46610: Anoscopy with Removal of Single Lesion
CPT code 46610 covers an anoscopy with removal of a single tumor, polyp, or lesion using hot biopsy or bipolar cautery. This minor operative procedure is commonly performed in ambulatory surgical centers or outpatient procedural settings and is an important code for colorectal, proctologic, and general surgery practices. Nationally, correct coding of 46610 affects clinical documentation, operative reporting, and payer adjudication for common anorectal lesion excisions.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on clinical intent and typical sites of service, plus guidance on what to expect in payer coverage patterns and billing considerations. The publication outlines benchmarks and policy-relevant updates that influence payment handling and utilization trends for minor anorectal procedures.
This analysis helps clinical managers, coding professionals, and policy analysts understand the scope and common uses of CPT code 46610, how it fits into procedural coding workflows, and where to focus documentation to support appropriate billing and claims processing. Data not available in the input for certain comparative metrics or diagnosis mappings is noted where applicable.
Billing Code Overview
CPT code 46610 describes an anoscopy with removal of a single tumor, polyp, or lesion performed using hot biopsy or bipolar cautery. The procedure uses a small, rigid, tubular instrument (anoscope) to visualize the anal canal and distal rectum and to excise a single lesion during the same encounter.
Service type: Minor operative procedure — anoscopic lesion removal
Typical site of service: Ambulatory surgery center or outpatient clinic/procedural room
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 52-year-old patient presents to an outpatient ambulatory surgery center with bright red rectal bleeding and a palpable anal mass on digital rectal/visual inspection. The colorectal surgeon performs a focused anorectal examination using a rigid anoscope under local anesthesia with monitored anesthesia care. During the exam, a single friable polypoid lesion approximately 1.5 cm is visualized within the distal anal canal. The surgeon removes the lesion using hot biopsy/bipolar cautery through the anoscope for hemostasis and sends the specimen for pathology. The procedure is documented with pre- and post-procedure vital signs, informed consent, indication, lesion location and size, technique (anoscopy with hot biopsy/bipolar cautery), estimated blood loss, specimen labeling, and discharge instructions. Typical site of service is an outpatient clinic procedure room or ambulatory surgery center.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Data not available in the input. | Data not available in the input. |
59 | Distinct procedural service | Use when the anoscopy with removal of a lesion is distinct/separate from another procedure performed at the same encounter on a separate anatomic site or session. |