Summary & Overview
CPT 46615: Anoscopy with Excision of Anorectal Lesion
CPT code 46615 denotes an anoscopy with excision of tumors, polyps, or lesions using methods other than hot biopsy forceps, bipolar cautery, or snare. This code captures a targeted operative procedure in the distal rectum and anal canal and is relevant to colorectal surgeons, general surgeons, proctologists, and gastroenterologists who perform minor anorectal operative work. Nationally, accurate use of this code affects outpatient procedure reporting, resource allocation in ambulatory surgical centers, and claims adjudication for anorectal pathology management.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The content addresses coding conventions, common clinical settings, and how the code is used in practice for lesion removal in the anorectal region.
Readers will learn the clinical scope of CPT code 46615, typical sites of service, and the procedural context for which it is reported. The publication provides benchmarks and coding guidance context, summarizes how major payers treat facility and professional claims for this type of anoscopic excision, and outlines policy considerations and documentation elements that commonly influence claim outcomes. Data not available in the input will be noted where applicable.
Billing Code Overview
CPT code 46615 describes an anoscopy with removal of tumors, polyps, or lesions using techniques other than hot biopsy forceps, bipolar cautery, or snare. The procedure uses a small, rigid, tubular instrument called an anoscope to visualize the distal rectum and anal canal and to perform excision of abnormal tissue.
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Service type: Procedural excision/operative anoscopy
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Typical site of service: Ambulatory surgical center or hospital outpatient department; may also be performed in an office procedure room depending on clinical setting and resources.
Clinical & Coding Specifications
Clinical Context
A 54-year-old patient presents to an outpatient colorectal clinic with intermittent rectal bleeding and a palpable anorectal mass on digital exam. An anoscopy with lesion removal is scheduled. The procedure is performed in an ambulatory surgery center under monitored anesthesia care. The provider inserts a rigid anoscope to visualize the anal canal and distal rectum, identifies a polypoid lesion at 4 cm from the anal verge, and removes it using cold excision (forceps and scissors) rather than hot biopsy forceps, bipolar cautery, or snare techniques. Hemostasis is achieved with direct pressure and topical agents. The specimen is sent for pathology. Post-procedure recovery includes vital sign monitoring, a brief assessment for bleeding or urinary retention, and discharge with wound care and activity instructions. Billing captures the anoscopic excision using 46615, an appropriate global period, and any applicable modifiers for anesthesia, unusual procedural circumstances, or multiple concurrent procedures.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a distinct E/M visit is documented on the same day as 46615 for a new problem or significant separate issue |